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ik^^assi 




Spondylotherapy 



By the Same Author 

Clinical Diagnosis. 

Third edition, revised and enlarged. 

The Blues. 

(Splanchnic Neurasthenia). Third edition. 

Auto-Intoxication. 

Causes, symptoms and treatment. 

Transactions of the Antiseptic Club. 

E. B. Treat & Co., New York. 

Diagnostic-Therapeutics. 

Drugs and remedial measures in the diagnosis of 
disease. Rebman Company, New York. 

SpOND YLOTHERAPEUTICS . 

The employment of remedial measures to the spinal 
region in the treatment of disease. 

Philopolis Press, San Francisco. 

Scattered Leaves from a Physician's Diary. 
Diseases of the Lungs and Pleura. 

Fortnightly Press Co., St. Louis. 

Diseases of the Heart. 

G. P. Engelhard & Co., Chicago. 

Nervous Breakdown. 

Hicks- JuDD Co., San Francisco. 

Consumption. 

Causes, prevention and cure. 

Wm. Doxey, San Francisco. 

Domestic and Personal Hygiene. 

Cohen's System of Physiologic Therapeutics. 

P. Blakiston's Son & Co., Philadelphia. 



SPONDYLOTHERAPY 

PHYSIO-THERAPY OF THE 
SPINE BASED ON A STUDY 
OF CLINICAL PHYSIOLOGY 



BY 

ALBERT ABRAMS, AM., M.D. 

Tu^IVERSITY OF HEIDELBERG) 

F. R. M. S. 

CONSULTING PHYSICIAN TO THE MOUNT ZION AND FRENCH HOSPITALS, 
SAN FRANCISCO; FORMERLY PROFESSOR OF PATHOLOGV AND DIRECTOR 
OF THE MEDICAL CLINIC, COOPER MEDICAL COLLEGE (DEPARTMENT OF 
MEDiaNE, LELAND STANFORD JUNIOR UNIVERSITY), SAN FRANaSCO 



THIRD EDITION, ENLARGED 



THE PATHOLOGY OF SPONDYLOLOGY IS FOUNDED 
ON CLINICAL PHYSIOLOGY AND ITS METHODS 
EMBRACE THE THERAPEUTICS OF THE REFLEXES 



PHILOPOLIS PRESS 

SUITE 406, LINCOLN BUILDING, SAN FRANCISCO, CALIFORNIA 

1912 



Cot9ri£ht,1910 

h 

Albert Abrams 
Ctpyrizht, 1912 

by 

Albert Abrams 















» * 



* % • 






11 



TO THE MEMBERS 

OF THE FACULTY OF MEDICINE, PARIS, 

IN RECOGNITION OF THEIR DISTINGUISHED SERVICES 

IN THE ADVANCEMENT OF MEDICINE AND 

FOR MANY ACTS OF COURTESY 

THIS BOOK IS DEDICATED 

BY THE AUTHOR 



R ^ '^^H"? 



Preface to the First Edition 

THE subject of spinal therapeutics has received less attention 
from the medical profession than it deserves. Even the laity 
know that cold applied to the back of the neck may arrest hemorrhage 
from the nose, and that heat applied to the small of the back may 
hasten menstruation. The profound and far-reaching physiologic 
truths which underlie these simple phenomena have either been 
ignored or only given inconsiderate attention. 

Others, less scientific but more astute, have determined empiric- 
ally that manipulation of the spine does sometimes cure conditions 
that have failed of cure in the hands of experienced physicians. 
So it has come to pass that schools of practice exploiting spinal man- 
ipulation as a cure-all have arisen. Neither the fury of tongue nor 
the truculence of pen can gainsay the confidence which these systems 
of practice have inspired in the community. 

The author was led to a deeper study of spinal therapeutics in 
investigating various visceral reflexes which bear his name. As the 
years {>assed on, he ascertained that a number of pathologic con- 
ditions could be more easily and certainly controlled by spondylo- 
therapeutic means, than by the conventional measures. 

Some phjrsidans may consider the remedial methods discussed 
in this book to be imduly and imworthily simple, on the principle 
that what is obvious can hardly compete with what is obscure in 
the treatment of disease. The most mystifying phenomena rest upon 
the least complex causes; and the simpler a thing is, the harder it is 
to imderstand. 

Anybody, however, who investigates the study of spinal thera- 
peutics in earnest, will discover that the simplicity is only apparent. 
The successful practice of spondylotherapy requires knowledge, 
observation and experience of the highest kind, and is comparable 
to the best effort in any other department of scientific medicine. 
Indeed, one of the author's truest motives has been to lift this whole 
subject of spinal therapy out of the low state in which it blunders 
onward, hitting or missing as the case may be, and rescuing it from 
the lowly esteem which physicians as a class have thus felt for it. 
He has endeavored to put it in a place befitting its scientific impor- 
tance, and to emphasize its great practical helpfulness in disease. 

vn 



Preface to the First Edition 

Any method of cure that is more or less new is inclined to be 
viewed critically by the formalist and traditionalist, and so it should 
be. The writer knows better than any one else can the incompleteness 
and imperfections of his work. It is really a pioneer efiFort and he 
only asks that it be judged as such. Indeed, the author hopes to 
receive many suggestions and if need be, corrections, and to profit 
by them. 

One word concerning the cases dted in illustration of the methods 
which the author has described in various parts of the book. These 
may seem more or less incredible, the outcome of enthusiasm, bias, 
of some defect of the power of scientific observation, or of judgment. 
Yet the cases cited are not the most remarkable that the author has 
encountered in his practice. Some of these cases have been deliber- 
ately suppressed with a feeling that many readers are hardly prepared 
to appreciate or to credit the results which may be achieved by an 
earnest study and practice of spondylotherapy. To eschew a remedy 
because we cannot gauge its material properties may be an act worthy 
of the scientist, but the aim of the physician is to cure disease. In 
the presence of a sick man, two questions are to be answered: ''What 
is the matter with him, and what will do him good?" Neither the 
pragmatical doctrinaire who accepts nothing but what is demonstrated 
morphologically, nor the representative of an exclusive sjrstem of 
practice, with his introspective reasoning, can aid therapeutics. The 
former forgets that the crudal test for the action of remedial measures 
is in their clinical application and that many of our most potent 
drugs have been inherited from the therapeutic acumen of our medical 
ancestors. ''The diseases of which we know the least pathology are 
the diseases which we treat successfully." Cure, as conceived by 
the introspectionist, cannot merit the imprimatur of the scientist, 
and for this reason, the author has endeavored to justify his con- 
clusions by demonstrable evidence. 

ALBERT ABRAMS. 
246 Powell Street, 
San FRANasco, Cal., 
January, 1910. 



vm 



Preface to the Third Edition 

THE favorable reception accorded to the previous editions, 
has induced the author to undertake the enlargement of this 
work by the addition of seven chapters (zii — ^zviii) and fifty new 
illustrations. 

When the first edition of this book was published, nearly two years 
ago, it was a pioneer effort and only the cognoscenti could correctly 
interpret its real significance, viz., that spondylotherapy was suggested 
by the study of human physiology, on the principle that, "The proper 
study of mankind is man." After this manner, clinical physiology 
is made the basis of clinical pathology. To launch an innovation 
in medicine, with its surfeit of theories and theorists, is fraught with 
much risk to the innovator and the author anticipated the usual fate 
accorded to the originator, tHz., coAdemnation, discussion and possibly 
acceptance. Neither fear of difficulty, nor adverse criticism, deterred 
him from regarding scepticism as an argimient against the truth of 
his observations. 

It is indeed unfortunate that our medical journals have not yet 
attained that Utopian condition, when they are eager to give space 
to the protestations of an author, who feels that his work has been 
misinterpreted or unjustly criticised. For the latter reason, the 
author may be pardoned for utilizing the bulk of this preface in 
refuting some reviews of the previous edition. The review of *^The 
Journal of the American Medical Association,^^ is discussed on page 
387. Occasionally, a reviewer has sat in the scomer's seat and 
hurled the cynic's ban. "There is a principle which is a bar against 
all information, which is proof against all argimient and which cannot 
fail to keep a man in everlasting ignorance ; this principle is con- 
tempt prior to examination." 

A reviewer asseverated that the book contained nothing that was 
particularly new. The latter conflicted with another reviewer who 
said, ^^ There are fifty pages scattered throughout the volume , any one 
of which could be torn out and be used as a starting point and an in- 
spiration for most valuable research work. The possessor of this book 
has a rich mine of startlingly suggestive knowledge .... and 
to the man of study who strives to reach ever better and more fruitful 

IX 



Preface to Third Edition 

methods of investigation and cure of disease, this book will be most 
welcome J^ 

In another publication a prominent surgeon commented as follows: 
'^Probably the most starUingly radical stared ever taken within tlte 
ranks of the medical profession was that announced this very year by 
Dr. Albert Abrams, of San Francisco, in his remarkable book, 
'Spondylotlterapy: " 

An eminent French clinician, in commenting on "Spondylotherapy," 
says: **Some of my results and those of my colleagues in Paris, by the 
methods of spondylotherapy are positively miracles^ 

Those "in authority"? who regard innovation from the view- 
point of heresy, recalls the bon mot by a witty compatriot of Talley- 
rand, who, in commenting on the conservatism of the latter said, if 
Talleyrand, had been present at the creation he would have exclaimed: 
**Good gracious! Chaos will be destroyed." 

"He who dreads new remedies must abide old evils." 

Yet another reviewer who questioned the right of a clinician to 
digress from traditional methods in the investigation of facts physio- 
logic, must be answered. It is not now imusual for the laboratory- 
physiologist, to preside at the birth of his theory one day, and for the 
dinidst to offidate at its burial on the morrow. Pavloff observes, 
"The physician gives a more correct verdict concerning physiologic 
processes than the physiologist himself." Hughlings Jackson, was 
one of the greatest sdentifiic neurologists, yet he never performed an 
experiment but formulated his conclusions in the wards of a hospital. 
Some of his enthusiastic prosel3rtes have arrogated to the author 
the questionable honor of having created a new system of medical 
practice. No system can exdusively preempt the field of thera- 
peutics, which is a composite practice founded on empiridsm and 
the practical application of pharmacology and other sdences in the 
treatment of disease and the innovationist must create no discon- 
tinuity in the transition to new knowledge. As an emphatic protest 
to such an assumption, the author has incorporated many facts 
relating to the employment of drugs in the treatment of disease 
and refers to his monograph, "Diagnostic-Therapeutics." When 
the author employed the neologism, spondylotherapy (G. Spondylos, 
vertebra + therapeia, treatment), he advocated no exclusive 
methods in spinal therapeutics, but employed all the resources of 



Preface to Third Edition 

scientific medicine bearing on the treatment of disease. Since the 
publication of his work, the author regrets that, some so-called "drug- 
less healers" are exploiting the term spondylotherapy to abet their 
exclusive methods of practice. For the benefit of physicians who 
cannot master some of the details of spondylotherapy, a practical 
course is given on this subject by the author from time to time. 

ALBERT ABRAMS. 
246 Powell Street, 
San Franctsco, Cal., 
February 1912. 



XI 



Contents 



CHAPTER I. 



HISTORICAL 

Primitive Era of Spondylotherapeutics 

The Griffin Brothers 

Swedish Gymnasts 

Osteopathy 

Chiropractic 

Dana .... 

Quincke 

Head . • • . 

The Vertebral Reflexes 



Page 



I 

2 



CHAPTER II. 

ANATOiaC, TOPOGRAPHIC AND PHYSIOLOGIC DATA. 

Structure of the Spinal Cord . . . . • i7 

Roots and Distribution of the Spinal Nerves . . i8 

Anatomic Landmarks . . . . • • ^9 

Symi>athetic System ..... 24 

Physiology of the Spinal Cord . . . . .26 

Localization of the Functions in Different Segments of the Spinal 
Cord •••••••3^ 



CHAPTER III. 



SYMPTOMATOLOGY. 

Examination of the Back 

The Normal Spine 

Spondylography 

Examination of the Muscles of the Back 

Stiff Back .... 

Muscular Hypotonia 



38 
38 
42 
46 

50 
52 



XIll 



n 



n 



Pain and Tenderness of the Spine 
Sympathetic Sensations 
Dermatomes of Head . 
Vertebral Pain 
Vertebral Tenderness . 
Vertebral Percussion 
Vibrosuppression 



Page 

• 55 

57 

■ 58 
66 

• 71 

79 
. 80 



CHAPTER IV. 



SUMMARY OF SPINAL DISEASES AND SYMPTOMS. 



Backache 

Chest Deformities . 

Coccygodynia . 

Faulty Attitudes 

Litigation Backs 

Lumbago . 

Neurotic Spine 

Osteo-Arthritis 

Pott's Disease of the Spine 

Sacro-Iliac Disease . 

Sacro-Iliac Relaxation . 

Spinal Curvatures . 

Scoliosis 

Kyphosis and Lordosis 

Angular Curvature 

Spondylitis . 

Spondylolisthesis 

Traumatism of the Spine 

Tumors of the Spine 

Typhoid Spine 

Vertebral Insufficiency . 

Diagnosis of Spinal Diseases 

Pains . 

Deformity . 

Compression of the Spinal Cord 



83 
94 

95 
96 
97 
99 

to5 
[08 

II 

II 

13 

13 

15 

17 

17 
18 

18 

21 

21 

22 

26 

28 

31 
33 



XIV 



n 



n 



Paraplegia 

Tuberculosis 

Syphilis 

Gonorrhoea 

Rheumatism 

Rickets 

Spinal Meningitis 



Page 

134 

• 137 

139 
. 141 

141 

. 143 
144 



CHAPTER V. 



GENERAL SPONDYLOTHERAPY. 

Abdominal Supporters . 

Acupuncture 

Counterirritation 

Electrotherapy 

Exercises .... 

Re-education of Co-ordinated Movements 

Spinal Hydro-Therapy . 

Lumbar Puncture . 

Massage .... 

Psychrotherapy 

Thermotherapy 

Vibratory Massage 



145 
146 

148 

151 
159 
165 
166 

167 
168 
172 

174 
I7S 



CHAPTER VI. 



PSEUDO-VISCERAL DISEASES 



Neuralgia 

Intercostal Neuralgia 
Differential Diagnosis . 
Pseudo-Appendidtis 
Pseudo-Cerebral Disease 
Pseudo-Angina Pectoris 
Pseudo-Arrhythmia 
Pseudo-Esophagismus 



182 
186 
189 
191 
192 
194 

195 
196 



XV 



n 



n 



BBBBBl 



Pseudo-Nephrdithiasis . 
Pseudo-Dyspepsia . 
Pseudo-Chdelithiasis . 
Pseudo-Mammary Neoplasms 



Page 

• 197 
197 

• 197 
198 



CHAPTER VII. 




THE CIRCULATORY SYSTEM. 




The Heart Reflex .... 


• 199 


Cardiac Sufficiency - . . 


3IO 


Differential Table of Asthma 


. 312 


Tests for Heart Sufficiency .... 


"S 


Angina Pectoris .... 


. 221 


The Heart Reflex of Dilatation 


221 


Differential Table of True and False Angina . 


. 224 


Functional Affections of the Heart . 


228 


Inhibition of the Heart 


. 228 


Physidogy and Pathdogy of the Blood- Vessels 


231 


Blood-Pressure ..... 


. 234 


Vaso-Motor Factor in Blood-Pressure 


239 


Sphygmomanometry .... 


. 244 


Hypertension and Hypotension 


246 


The Aortic Reflexes .... 


- 254 


Aneurysm of the Thoracic Aorta . 


254 


The Vaso-Motor Apparatus 


. 272 


Vaso-Motor Neuroses .... 


27s 


CHAPTER VIII. 





THE RESPIRATORY APPARATUS. 



Physiology 

Histology 

Postural Lung-Dullness 

Lung Reflex of Dilatation . 

Lung Reflex of Contraction 



288 
289 
290 
294 
298 



XVI 



n 



n 



Pulmonary Atelectasis 
Bronchial Asthma 
Spasmodic Bronchostenosis 
Tuberculosis 
Hemoptysis 



Pagt 
299 

• 303 
3" 

• 31S 
315 



CHAPTER IX. 




THE DIGESTIVE SYSTEM. 




The Stomach ..... 


. 316 


The Stomach Reflexes .... 


316 


Percussion of the Stomach 


. 32» 


Treatment of Diseases of the Stomach 


324 


The Intestine ..... 


• 3*5 


The Intestinal Reflexes . . . »^ 


325 


Diseases of the Intestines 


. 326 


Treatment of Constipation .... 


3*9 


The Intestinal Neuroses 


• 330 


The Liver ...... 


331 


Hepatic Toxemia .... 


• 334 


Splanchnic Neurasthenia .... 


345 



CHAPTER X. 



MISCELLANEOUS REFLEXES. 



The Spleen 
Reflexes of the Spleen 
Splenic Reflexes in Treatment 
Uterus Reflex 
Dysmenorrhea . 
The Bladder Reflex 
The Kidney Reflexes . 
Nervous Symptoms 
Ps^ysiSy Contractures, Ataxia 



351 
352 

352 
358 
358 
358 

359 
362 

362 



XVII 



n 



n 



CHAPTER XL 




THE THERAPEUTICS AND DIAGNOSIS OF PAIN. 






Page 


Segmental-Analgesia ...... 


. 366 


Concussion-Analgesia ..... 


367 


Segmental-Localization ..... 


• 367 


The Trigeminus Nerve ..... 


371 


Sinusoidal-Analgesia ...... 


• 374 


Segmental-Psychrotherapy .... 


375 


Segmental-Analgesia of the Viscera .... 


• 376 


Segmental- Analgesia in Diagnosis 


377 


Physiology of Spondylotherapeutic Methods 


• 379 


Spinal Nerve-Tnmk Analgesia .... 


382 


Cortical Sinusoidalization ..... 


. 383 


CHAPTER XII. 





THE REFLEXES AND THE PERIPHERAL SYMPTOMATOLOGY 

OF VISCERAL DISEASE. 

Purport of Spondylotherapy ...... 387 

General Features of Reflexes ..... 390 

Therapeutics of Reflexes ...... 392 

Therapeutics of Concussion ..... 394 

Comparison of Methods . . . . • -397 

Trophic Functions of Cord ..... 400 

Trophic Diseases . . . . . . .401 

Peripheral Reflex Phenomena . . . . .411 

Insuflfidency of the Foot . . . . . .421 

Test for the Splanchnic Circulation . . . .427 

Reflexes of the Cranial Nerves ..... 440 



CHAPTER XIII. 



TONUS OF THE VAGUS AND PHARMACOLOGY OF THE REFLEXES. 



Tonus of the Vagus .... 
Anatomy of the Vagus . . . - 

Physiology and Clinical Physiology of the Vagus 



446 
446 
448 



XVIII 



n 



n 



Page 
Diagnosis of Vagus-Tonus ..... 453 

Vagus-tone and the Sense Organs . . .462 

Psychovagus Tone ...... 466 

Methods for Increasing and Decreasing Vagus-tone . . 469 

Therapeutic Results ...... 474 

Diseases Caused by Vagus-hypertonia and Vagus-hypotonia . 479 
Phyiogenetic Diseases ...... 500 

Vagal Hjrperesthesia ....... 504 

Clinical Pharmacology ...... 504 

CHAPTER XIV. 

FURTHER ADVANCES IN THE DIAGNOSIS AND TREATMENT 
OF DISEASES OF THE CIRCULATORY SYSTEM. 

Tests For Heart-Sufl5dency . 

Kuatsu 

Heart-Failure . 

Functional Cardiac Murmurs 

Reflex of the Pulmonary Artery 

Inhibition of the Heart 

Cardioptosis 

Subclavian Murmurs 

Angina Pectoris 

Anginoid Pains 

Phrenic Nerve . 

Diaphragm Reflex 

Aneurysm 

Fluoroscopy of the Aorta 

CHAPTER XV. 

FURTHER ADVANCES IN THE DIAGNOSIS OF DISEASES 
OF THE DIGESTIVE SYSTEM. 

Percussion of the Stomach ...... 584 

Diagnostic Data ....... 588 

Percussion of the Intestines . . . . . -591 

The Gall-Bladder . . . . . . -597 

Diagnostic Data ....... 599 

The Pancreas ....... 600 



. 510 


515 


• 523 


525 


. 526 


- 5*8 


• 529 


533 


• 539 


540 


• 549 


550 


- 550 


. S6i 



n 



n 





Page 


CHAPTER XVI. 




PHYSIO-THERAPY OF PULMONARY TUBERCULOSIS. 




Anemic Theory ...... 


• 602 


Clinical Evidence ....... 


603 


Triangles of Grocco ...... 


. 606 


Methods for Eliciting Lung-Hyperemia 


608 


R^sum^ ........ 


. 608 


TreatmeAt ........ 


609 


Author's Treatment ...... 


. 613 


Visceral Vascularity ...... 


614 


Blood-Volume ....... 


. 617 


CHAPTER XVII. 





TREATMENT OF WHOOPING COUGH. 



Pertussis . . . , 

Author's Conception of Pertussis 
Author's Treatment 
Results of Treatment . 
Analysis of Treatment 



619 
620 
624 
624 

627 



CHAPTER XVIII. 



MISCELLANEOUS DATA. 



Further Advances in the Utilization of the Kidney Reflexes 
Prostatic Hypertrophy .... 

Reflexotherapy ...... 

Spondylotherapy in the Etiology of Disease 

Synoptic Table of Spondylodiagnosis 

Synoptic Table of Spondylotherapy 

Synoptic Table of Pharmacology of the Reflexes . 

Spondylotherapeutic Armamentarium . 

Bibliography ...... 

Index ...... 



• 629 

634 
. 636 

640 
. 642 

644 
. 644 

646 
. 657 

661 



XX 



Illustrations 



Figure. 

1. Illustrating the Chiropractor's Conception of Disease 

2. Plexor and Pleximeter for the Vertebral Reflexes 

3. Concussing the Spines with the Hands 

4. Spinal Musciilar Reflexes 

5. Viscero-Motor Reflexes .... 

6. Babinski Toe-Reflex .... 

7. Conducting Paths in the Spinal Cord 

8. A Spinal Nerve .... 

9. Composition of a Peripheral Nerve-Trunk 

0. Relations of the Segments of the Spinal Cord . 

1. Posterior Aspect of the Thorax and Abdomen 

2. Sympathetic and Cerebro-Spinal Nervous System 

3. Mechanism of the Knee-jerk 

4. Showing Spinal Segments for Motion and Sensibility 

5. Segmental Skin Fields 

6. Normal Vertebral Curves . 

7. Spond^ograms 

8. Apparatus for Taking a Spondylogram 

9. Vertebral Areas of Muscular Spasm . 

20. Plan of the Cervical Plexus 

21. Diagrams of Transferred Pains 

22. illustrating Cutaneous Tenderness 
Sensory Areas of the Skin (Anterior View) 
Sensory Areas of the Skin (Posterior View) 
Sensory Areas of the Skin 
Sensory Areas of the Skin 
Painful Head-Areas Related to Visceral Disease 
Hyperalgesic Zones .... 
Hyperalgesic Zones .... 
Areas of Vertebral Tenderness 
Areas of Vertebral Tenderness 
The Vibrosuppressor .... 
EflFects of a Dilated Stomach on the Heart 
Area of Lung-Dullness in Dislocation of the Heart 
Sites of Indurations .... 



23- 
24. 

25. 
26. 

27. 

28. 

29. 

30- 
31- 
32. 

33- 
34. 

35- 



Page 
6 

9 
10 

13 
14 
16 

18 

19 
20 

22 

25 

27 

31 

35 
40 

42 
43 
49 
51 
56 

58 
61 

61 

63 
63 

65 
67 
68 

75 

78 
81 

85 
86 

90 



XXI 



/ / / 



u 



a 



n 



Figure. 

36. Electric Massage-Apparatus 

37. Curves in Kyphosis and Lordosis 

38. Relation of the Spinal Cord 

39. Spinal veins . 

40. Areas for Counter-Irritation 

41. Areas for Counter-Irritation . 

42. A Sine Curve 

43. The Author's Sinusoidal Apparatus 

44. Kellogg's Sinusoidal Apparatus 

45. The Victor Sinusoidal Apparatus 

46. Interrupting Electrodes 

47. Electro-Motor Points of the Muscles of the Back 

48. Vertebral Areas for Eliciting Visceral Reflexes 

49. Cutaneous Areas for Influencing the Viscera . 

50. Pneumatic Hammer 

51. Electric Concussion-Hammer . 

52. Diagram of a Thoracic Nerve 

53. Cutaneous Nerves of the Thorax and Abdomen 

54. Illustrating the Heart Reflex 

55. Bkifltrating' the Heart Reflex . 

56. Sphygmogram After Inhaling Ammonia . 

57. Illustrating the Heart Reflex . 

58. Illustrating the Heart Reflex 

59. Sphygmogram After Straining at Stool . . 

60. Illustrating the Heart Reflex in Myocarditis 

61. Illustrating the Heart Reflex in Myocarditis . 

62. Illustrating the Heart Keflex After Using Digitalis 

63. Position of Leg for Palpating the Tibial Artery 

64. Demonstrating the Amplitude of the Heart Reflex 

65. Position of Head to Inhibit the Heart 

66. Sphygmomanometer .... 

67. Rubber-Ring for Excluding Auto-Pulsations 

68. Relation of Heart and Aorta to the Chest- Wall 

69. Aortic Reflex of Contraction in Aneur3rsm 

70. Aortic Reflexes in Aneur)rsm (Posterior View) 

71. Aortic Reflexes . . . - 

72. Aortic Reflexes of the Abdominal Aorta 



Page 


. lOI 


116 


. 119 


127 


. 148 


149 


. 152 


^S3 


- 154 


^SS 


- 156 


IS7 


- 170 


174 


. 177 


179 


. 183 


184 


. 200 


201 


. 202 


206 


. 206 


208 


. 220 


220 


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226 


. 227 


. 228 


245 


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254 


• 25s 


255 


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263 



XXII 



Ill 



u 



a 



n 



Figure 

73. Reflex of the Abdominal Aorta 

74. Path of a Vasoconstrictor Nerve .... 

75. Photograph of Exophthalmic Goitre . 

76. Photograph of Exophthalmic Goitre 

77. Types of Breathing ..... 

78. Diagram of the Respiratory Center 

79. Atelectatic Zones ..... 

80. Atelectatic Zones ...... 

81. Illustrating the Bronchial Tubes in Asthma 

82. Arrangement of Bottles for Promoting Lung-Contraction 

83. Nerves of the Stomach 

84. niustrating Traube's Space 

85. Effects of Ether-Inhalation on the Stomach 

86. Percussion of Stomach by the Vago- Visceral Reflex 

87. Liver Reflex of Contraction . 

88. Liver Reflex of Dilatation . 

89. Cardio-Splanchnic Phenomenon 

90. Splenic Reflexes .... 

91. Kidney Reflexes 

92. Skin-Areas Related to Spinal Segments . 

93. Skin-Areas Related to Spinal-Segments 

94. Peripheral Distribution of Sensory Nerves 

95. Peripheral Distribution of Sensory Nerves 

96. Location of the Gasserian Ganglion 

97. Localization of the Motor Area 

98. Concussor ..... 

99. Mcintosh Polysine Generator 
100. Double Vacuum Electrode .... 
loi. Illustrating Origin and Distribution of Autonomic Fibers 

102. Course of Autonomic Fibers .... 

103. Patches of Dullness of the Splanchnic Vessels 

104. Dullness in Insufficiency of the Splanchnic Vessels 

105. Diagram of Pilo-Motor Reflexes 

106. Illustrating Mechanism of Reflexes 

107. Diagram of a Spinal Nerve .... 

108. The Ocular Nervous System .... 

109. Diagram of the Vagus Nerves 



Page 
265 

273 
282 

283 
289 

290 

300 

300 
30S 

314 
317 
318 

319 

322 

332 

333 
346 

353 
. 360 

368 

. 368 

372 

• 373 
374 

. 384 
396 

- 398 

399 
412 

426 

- 433 
433 

• 436 
438 

- 440 
442 

• 447 



XXIII 



Illustrations 

Figure Page 

10. Illustrating the Effects of Pilocarpin on an Aneurysm 458 

11. Illustrating the Action of Adrenalin on an Aneurysm . 459 

12. Radicularpressor ...... 468 

13. Cardiac Nerves in the Rabbit .... 469 

14. Base-Knob ....... 476 

15. Heart Reflex by Extension of Cervical Muscles . •477 

16. Apparatus for Paravertebral Pressure . . . 478 

17. Tracings in Exophthalmic Goitre .... 493 

18. Illustrating Threshold Percussion . . . 511 

19. Cardiac Nerves . . . . . -519 

20. Illustrating the Rose Bandage . . . .531 

21. Method for Supporting the Abdomen . . - 532 

22. Contents of the Mediastina .... 554 

23. Boundaries of Heart and Great Vessels . . -557 

24. Percussion-Zones of the Spine . . . -559 

25. Postural Method of Percussing the Aorta . . . 560 

26. Fluoroscopy of the Aorta . . . . .561 

27. Radioscopy of the Aorta . ... . - 563 

28. Percussion-Areas of an Aneurysm . . . 565 

29. Apparatus for Taking Tracings of the Aorta . . 566 

30. Aortograms . . . . . . .567 

31. Aneurysm of the Thoradc Aorta . . - - 571 

32. Intrathoracic Shadow (Misinterpreted) . . . 576 

33. Primitive Apparatus for Concussion .... 582 

34. Radioscopy of the Stomach .... 584 

35. Diagrammatic Outline of the Stomach . . . 585 

36. Percussion of the Stomach (Vago- Visceral Method) . 587 

37. Intestinal Areas of Dullness by Paravertebral Pressure . 593 

38. Topography of the Alimentary Canal . . 594 

39. Gall-Bladder (Method of Locating) .... 598 

40. Vascular Supply of an Alveolus .... 602 

41. Vascular Parallelogram and Triangles of Grocco . . 607 

42. Arrangement of the Pulmonary Blood- Vessels . . 609 

43. Mask of Kuhn ....... 610 

44. Reclining Chair of Jacoby . . . . 611 

45. Tracheo-Bronchial and Broncho-Pulmonary Glands . 622 

46. Posterior View of the Opened Head, Neck and Trunk 631 
Spondylotherapeutic Armamentarium . . . 648 

XXIV 



S POND YLOTH ERA PY 



CHAPTER I. 

HISTORICAL. 

PRIMITIVE ERA OF SPONDYLOTHERAPEUTICS — THE GRIFFIN BROTHERS 
— SWEDISH GYMNASTS — OSTEOPATHY — CHIROPRACTIC — DANA — 
QUINCKE — HEAD — ^THE VERTEBRAL REFLEXES. 

TN the primitive era of hydrotherapy, the application to 
the spinal region of the hot-water bag and ice-bag was 
a conventional procedure dictated by empiricism with little 
physiologic knowledge concerning the action of water on 
the spinal centers. Even at the present day, our thera- 
peutic armament embraces various physical methods which 
are indiscriminately employed with neither rhyme nor reason. 
Thus therapeutics is discredited and any good results achieved 
from treatment are attributed to suggestion. We dare not 
wholly ignore the physical methods of treatment even though 
there is no physiologic reason to justify their employment, 
although it should be the constant effort of the physician to 
rationalize his methods. We are not justified in discrediting 
clinical observations because they have not been confirmed 
in the laboratories. Gowers observes, **The diseases of 
which we know the least pathology are the diseases which 
we treat successfully." 

We should be prepared to welcome new truths, even 
though, as Gee the observed, they threaten to overturn 
beliefs which we have entertained for years and have handed 
-down to others. 

One must not forget, however, the unconscious tendency 
of specialists to exaggerate the importance of some special 
method of treatment. 



Sp^fidjlatk 



a p J 



In die preseoce of abc&uximal pnx, tbe szE^Boa who 1^ 

hm hi»i as -ireil as ais knfe Amis at appcaficafe, but wfatn 
be J»^ Hw knife ta ±e odaaba at rtK feai be timiks of 
rwSim^ dfie. Tnere s tne 2?TacDjGgKt wfuee cancepckMi 
/>f riw#«»e i-H limiteri lij tie hdkus and :uhu^^a and diere is 
fhe oculwt ^-tH rn i *nt a l asOCTat^zu w&o rcAects iis sab- 
^Xi^ty ^n die exanunatioa of fe paripnts 

We stll kn#>w the tendency to paxromas special off^ans, 
4i<%r«5W« ^>r remedies, and the poet Ciafafae, in Tose, tfaus 
bwiry^^Kzefi th» tendency: 

'^^/ne t^# th€ gr^ot amtnca all bmiian poia, 
fte riew% it raging in the frantic bnin; 
f'ifv^ft if in fever*, all his efforts mar, 
Aft4 v^'j^ it larking in the cold catanii. 
Bili^i*!* \ij v>me, by others nerroos seen, 
kffH^^. the fantaAti/: demons of the spleen; 
Af>/1 rtrery %ym\A/mi fA the strange disease, 
Wifh 9:v9:ry %y%Um of the sage agrees." 

THK GKIKFIN BROTHERS. 

In /Hff William anrl Daniel Griffin, physicians, respect- 
Ivi'ly, of fC^linl/urj<h and I><;ndon, published a woii in which 
l/jM rtt<»#*<i wiTfr analy/y4!(l showing the relation of certain 
^yrnplonm lo drfinili* »i)inal regions. These symptoms were 
nniMiilMtrd wllh ftpinal tenderness in fixed regions. They 
lonihidrd IHmI fhr IrndrrncHs in question was either primary 
Iti Ihi* ftpliinl nird or wcondary to visceral or other diseases. 
Thf^ (Irldiii Mhilhrrw ((iirnrd as follows: "We should like 
to Icntrn why |iirwmiro on a particular vertebra increases, or 
nKcltrw, \\w ilUrawp aiNMtl whirh wc are consulted, why it 
at onr Ihnr rnrllrw htMidac hr or rnmp or sickness of the 
Mninarh.'* "Why, In mww hmlaiuvs, any of these complaints 
n\ay W lallod \)p al will l»v ttuu hinn a corresponding point 



The Griffin Brother 



of the spinal chain?" The following table by the GriflSn 
Brothers* demonstrates the tender areas of the spine: 



CASES. 

Twenty-eight cases of 
cervical tenderness, 
8 men; 8 married, 
12 unmarried. 

Forty-six cases of cer- 
vical and dorsal 
tenderness, 7, 15 
married, 24 un- 
married. 

Twenty-three cases of 
dorsal tenderness, 
4, o - - 6 married, 
16 unmarried. 



Fifteen cases of dorsal 
and lumbar; i man; 
II married, 3 un- 
married. 

Thirteen cases of lum- 
bar tenderness. 



Twenty-three cases, 
all of the spine, 4, o 
-4 married, 15 un- 
married. 

Five cases; no tender- 
ness of the spine. 



PROMINENT SYMPTOMS. 

Headache, nausea or vomiting, 
face-ache, fits of insensibility, af- 
fections of the upper extremities. 
In 2 cases only, pain of stomach; 
In 5, nausea and vomiting. 

In addition to the foregoing 
symptoms, pain oi stomach and 
sides, pyrosis, palpitation, ofH 
pression. In 34 cases, pain of 
stomach. In 10 cases, nausea 
or vomiting. 

Pain in stomach and sides, 
cough, oppression, fits of syn- 
cope, hiccough, eructations. In 
one case only, nausea and vomit- 
ing. In almost all, pain of 
stomach. 

Pain in abdomen, loins, hips, 
lower extremities, dysury, isch- 
ury in addition to the symptoms 
attendant on tenderness of the 
dorsal. In i case only, nausea. 

Pains in lower part of abdo- 
men, dysury, ischury, pains in 
testes or lower extremities, or 
disposition to paralysis. In i 
case only, spasms of stomach and 
retching. 

Combines the symptoms of all 
the foregoing cases. 



Cases resembling the foregoing. 



Spondylotherapy 

At this period (1834) Swedish gymnasts, notably Ling, 
observed among cardiopaths, tenderness over the 4th or 5th 
dorsal nerves when this region was subjected to friction. 
The Swedish school recognizes definite areas of spinal ten- 
derness identified with the various organs. Thus, in affec- 
tions of the stomach, tenderness is observed in the region of 
the 6th, 7th and 8th dorsal nerves on the left side, and man- 
ipulation of the region in question often evokes eructations 
of gas. 

In 1 84 1 Marshall Hall published his memorable work 
which established the importance of the spinal reflex. 

OSTEOPATHY. 

In 1874 osteopathy was founded. It was based on 
the theory that health signifies a natural flow of blood and 
that the bones may be employed as levers to relieve pressure 
on nerves, veins and arteries. The pressure is assumed to 
be caused by dislocated bones, and, when the osteopath 
refers to a "lesion," he intimates malposition of a bone. 

The theory of the osteopath may be at variance with 
our accepted views of etiology, yet the latter, by his manipu- 
lations, unconsciously evokes reflexes which are cogent 
factors in favorably influencing disease. 

The osteopath indignantly resents any comparison of his 
system to massage. The following statement occurs in a 
representative work on this system by G. D. Hulett^ 
"Masseurs are aware of the fact and the possible significance 
of tender points in the tissues along the spine over the area 
from which the nerves are given off to the organs which are 
in a diseased condition; evidently, however, they have con- 
sidered these tender points as always secondary to the dis- 
eased viscus." "The essential distinction between osteop- 
athy and all other systems of healing," continues the same 

4 



Chiropractic 

writer, "based on manipulation, clusters around the etiology 
of disease." In other words, in disease of an organ, the 
masseur acts directly upon the organ; but the osteopath 
taking into consideration what he regards as a fact "The 
ability of nature to functionate properly, treats the central 
force." 

According to the foregoing, the osteopath regards disease 
from a central and not from a peripheral standpoint. 

CHIROPRACTIC. 

This system was founded in 1885. The theory sustaining 
this system presumes that, in consequence of displaced 
vertebrae, the intervertebral foramina are occluded through 
which the spinal nerves pass (Fig. i). 

In this way the nerves are pinched and chiropractors 
assume that such pinching is responsible for 95 per cent of 
all diseases. Chiropractic concerns itself with an "adjust- 
ment" of the subluxations, thus removing pressure on the 
nerves. 

What the chiropractor calls "nerve-tracing," consists of 
following a sensitive nerve from its vertebral exit to and from 
the affected organs. The chiropractor differentiates his 
method from osteopathy by the following asseverations : 

1. The hands are used in a different manner and the 

movements are dissimilar; 

2. The etiology of disease is unlike that accepted by 
osteopathy; 

3. Chiropractors "adjust" for more diseases than osteo- 
paths and the results are immediate. 

It is known that pain may be felt at a point distant from 
the actual site of a lesion. Such pains are know as trans- 
ferred PAINS. Thus the pains sometimes felt in the 

5 



S -p n d y I t h 



rap 




Fig. I. — Iltunming the chiiDpractor's coiKxptJOD of disease. A, the n 
are in the oormal posiiion with ihc spinal vindow open (SWO): B, showint; ll 
with >□ open spio&l window (he ncrvr i» nol conipirUed. Thr dollnl lines show 
the correct alignment of the spinous piocesf«s: C, the spinal window is dosed 
(SWC) owing to displaced vertebra and in consequence the nerve at ils exit is 
pandwd (D). (.Utei Palmer.) 



The Vertebral Reflexes 

mammary gland in uterine disease and in the knee in hip- 
joint disease are transferred or referred pains. 

The well-known illustrations of Dana (page 56) represent 
the location of transferred pains. 

In 1890 Quincke studied the sites of sympathetic 
SENSATIONS (page 57). 

Still later, in 1893, Henry Head, of London, demonstrated 
that in visceral disease, pain and disturbed sensation may 
be referred to definite cutaneous areas (vide page 58). 

THE VERTEBRAL REFLEXES. 

In medical literature the author has referred repeatedly 
to certain visceral reflexes elicited by cutaneous irritation, 
viz., the hmg refleooes of dilatation' and contraction*, the 
heart reflex^ y liver reflex^ ^ stomach and intestinal reflexes'' ^ 
and the aortic refleoces^. 

The reflexes in question are endowed with more than 
mere physiologic interest. They yield unequivocal demon- 
stration of the fact that the sensory peripheral nerve ter- 
minations receive impressions which are conducted, com- 
municated or reflected by aid of the nervous system. 

Such impressions react on the viscera and the manifesta- 
tions of the reaction may be utilized in a diagnostic and 
therapeutic direction. 

The evidence heretofore adduced in explanation of the 
results achieved by electric, hydriatic, mechanic and bal- 
neary treatment of disease was naught else than a mere 
array of words conceived only in conjecture. 

The cutaneous visceral reflexes referred to, suggest the 
rationale of the different peripheral methods of treatment. 

Visceral reflexes may be evoked not only by cutaneous 
irritation but likewise by concussion and the application of 

7 



Spondylo therapy 

the sinusoidal current to the spinous processes of the verte- 
brae. 

Reflexes elicited from the spinous processes have been 
specified by the author as vertebral reflexes.* 

The manipulation of definite vertebrae corresponds with 
the elicitation of specific reflexes, but, if the spinous processes 
are promiscuously manipulated, counter-reflexes are evoked 
which nullify the reflexes sought. As we proceed with our 
subject, we will determine that vertebral manipulation is 
influential for weal or woe in the treatment of disease and 
it will be the endeavor of the author, to endow spondylothera- 
peutics with some scientific accuracy and thus substitute 
order for chaos. 

To excite the vertebral reflexes for therapeutic purposes, 
concussion by means of an apparatus (page 176) or the 
sinusoidal current (page 151) is employed. For diagnostic 
purposes, either the sinusoidal current or simple concussion 
after the manner to be described is used. When the current 
is employed, the moistened, indifferent pad (usually large) 
is placed over the sacral region, whereas an interrupting 
electrode (Fig. 46), which permits one to close and open the 
circuit, is placed over definite spinal processes. 

For simple concussion the author employs a piece of soft 
rubber or linoleum about 6 inches long, i\ inches wide, and 
about a J of an inch in thickness as a pleximeter for receiving 
the stroke and a plexor with a large piece of thick rubber 
for delivering the blow (Fig. 2). 

The plexor used by the author is similar to that employed 
by French clinicians for obtaining the knee-jerk and is 
knowTi as the plexor of D^jerine. 

In the absence of the latter, a mallet or even an ordinary 
tack -hammer will suffice. 

One may also strike the spinous processes with the 

8 



The Vert e 



I te'fj'i 




¥ia. 3. — Plexor and pleximeler employed for eliciting the vertebral reflexes. 



knuckles or better still, the fingers may be used as a plexi- 
meter and the clenched fist as a plexor. In the latter instance, 
the palmar surfaces of the fingers are applied to the spinous 
processes to be concussed, and, with the clenched fist, the 
dorsal surfaces of the fingers are struck a series of short and 
vigorous blows (Fi^. 3) , 

The use of a pleximeter and plexor is decidedly more 
effective than the latter method which is only employed in 
an emergency. Here the strip of linoleum or rubber is 
applied to the spinous process or processes to be concussed, 
and, with the hammer, a series of sharp and \*igorous blows 
are allowed to fall upwn the pleximeter. 



S p 71 d y i t h e r a p y^ 




Naturally, the blows jar the patient somewhat, but be-l 
yond this no inconvenience is suffered. 

The vertebral reflexes, when the stimulant is concussioi 
are probably due to transmitted mechanic stimulation of tl 
roots of the spinal nerves, insomuch as many physiologisi 
contend that the spinal cord does not react to direct stimuli, 
In some instances concussion is more effective than the 
sinusoidal current in eliciting certain vertebral reflexes, 
whereas, In other instances, the current supersedes concus- 
sion. The relative value of these methods, however, will 
studied in detail in succeeding chapters. There is yet an- 
other method for eliciting the vertebral reflexes by means 
10 



I 



The Vertebral Reflexes 

pressure at the vertebral exits of definite spinal nerves 
(page 169). 

Reference to Fig. 4 shows the spinal muscular reflexes 
thus far elicited by the author, whereas, Fig. 5 represents the 
viscero-motor reflexes of spinal origin. The latter, with the 
exception of the aortic reflexes, probably act on the muscu- 
lature of the organs independently of the vaso-motor system. 

Unstriped or involuntary muscular fibers are present in 
practically all the organs of the body. Even the liver is not 
exempt. Here the muscular fibers contained in the fibrous 
coat of the organ enter the organ at the transverse fissure. 

The viscera, even in health, vary in size, and this alter- 
nate enlargement and diminution in bulk is due in part to 
variations in the supply of blood and in part to the contract- 
ility of the visceral musculature. 

If I am permitted to digress for a moment to give expres- 
sion to my prejudiced conception of many morbid manifesta- 
tions, I witness muscular tissue in a state of incoordination , 
uncontrolled by will and subordinated to the vagaries of un- 
disciplined reflex centers, the muscular orgy presents the 
tableau of muscles gone mad. Practically everywhere 
throughout the organism where muscle is found, fibers co- 
exist which dilate or contract. When neither function pre- 
dominates there are no morbid manifestations; in other 
words, a normal function is a question of muscular equilib- 
rium. The moment one set of fibers gains the ascendancy 
over its antagonist the symptomatic picture is made up of 
spasm or paralysis (vide Asthma, page 303). 

SPINAL MUSCULAR REFLEXES. 

These reflexes are best elicited by means of a powerful 
sinusoidal current after the manner already described (page 
11). Concussion by means of the plexor and pleximeter 

11 



S p 71 d y i 



t h 



a p y\ 



will also excite some of them. It will be observed that the 
reflexes in question arc bilateral, in contradistinction to the 
conventional cutaneo -peripheral reflexes, which areunllateral. 

For the convenience of their clinical elicitation they have 
been studied with relation to definite vertebral spinoi 
processes. 

It must be observed, however, that the areas in question 
may vary in different patients, but, as here cited, the areas 
are approximately correct. Like all reflexes, the degree of 
stimulation necessary for their excitation varies with the indi- 
vidual, but, as a rule.powerfulcurrents arenecessary. Practi- 
cally every muscle, or group of muscles, may be brougln to 
contraction, but, insomuch as this work is designed for a 
utilitarian rather than an academic purpose, only a few mus- 
cular reflexes thus far elicited by the author will be cited. 

1. Sterno-cleido -MASTOID KEFLEX. — This Is best ol 
served when the head is flexed and when the interrupting 
electrode is fixed over the spinous process of the 7th cer\'ical 
vertebra. Concussion of the latter will also evoke the 
reflex. This bilateral reflex is most pronounced at thea 
stemo -clavicular attachment of the muscles. 

2. Biceps, triceps, and wrist -jerk. — Elicited 
concussion of the spinous processes of the 5th and 6th cer\ncajJ 
vertebrse or by application of the current to the same proc- 
esses. Here the processes are concussed in succession or 
the electrode used is large enough to embrace both spinous 
processes. The upper extremities must be placed in a state 
of flexion, with muscles absolutely relaxed and the elbows, 
resting in either hand of an assistant. The elbows may also| 
rest on a table in the flexed position and relaxed. 

3. Palmar reflex. — This consists of a contraction 
two or more fingers when the interrupting electrode is 
plied over the spinous process of the 6th cervical vertebra. 



ai. 

.ve ^J 





The Vertebral Reflexes 

4. Pectoral reflex. — The patient lies on his side 
with arms elevated to bring the pectoral muscles into slight 
prominence, after which the dor^sal spinous processes (3d to 
the 6th) are either concussed or sinusoidalized. 

5. Scapular reflex. — Concussion or sinusoidalization 
of the 5th cervical spinous process. 






^^<% 









^^ ^,^-ftcr<i«AL 






S*-^: 



^^ifi^ 



f^iTnic 







^ Gl</7]£/V. 



^fhlNCTFR/!«^'-9— - • — g 



I--V. 






''tAfii-^, 



/» 



— — a-AcmLLfS 



Fig. 4. — ^The spinal muscular reflexes. 

6. Epigastric reflex. — Concussion or sinusoidaliza- 
tion of the dorsal spinous processes (7th to the 9th). 

7. Gluteal reflex. — When the patient is on his side 
sinusoidalization or concussion of any of the lumbar verte- 
brae. The reflex is accentuated as the last lumbar vertebra 
is attained. 

8. Cremasteric reflex. — ^When the ist, 2nd and 3d 
lumbar vertebrae are concussed or sinusoidalized. 



13 



S p 



n 



I 



t h 



r a p y 



9. Sphincter ani reflex. — Sinusoidalization with a 
small electrode at a point corresponding to the sacro-coccy- 
geal articulation. 

10. Adductor reflex. — ^Adduction of both lower ex- 
tremities when the spinous processes of all the lumbar verte- 
brae are sinusoidalized or concussed. The patient sits on 
a chair with both lower extremities extended and relaxed. 















^1 ^t ^(^f^ppca 



Fig. 5. — Visccro-motor reflexes of spinal origin. 



II. Quadriceps reflex. — With the patient seated and 
legs extended, concussion or sinusoidalization of the spinous 
process of the 2nd lumbar vertebra will produce a decided 
contraction of the quadriceps femoris. It may be noted that 
it is a contraction of this muscle which is responsible for the 
patellar reflex (knee -jerk) . When one leg is crossed upon 
the other (the conventional position for eliciting the knee- 
jerk), a knee-jerk can be obtained in the norm. In 

14 



The Vertebral Reflexes 

several tabetics in whom the knee-jerk was absent (by 
tapping the patellar tendon) it was very much exaggerated 
in either one or the other leg when one leg was crossed upon 
the other during sinusoidaUzation (with the interrupting 
electrode) of the spinous process of the 2nd lumbar vertebra. 
The foregoing phenomenon is discussed on page 28. 

12. Achilles reflex. — The patient rests on his knees 
on a chair, with feet projecting over the edge of the latter. 
In the conventional way, striking the Achilles tendon results 
in flexion of the foot. 

With the patient in the same position the interrupting 
electrode is fixed over the sacrococcygeal articulation, where- 
as the large pad is applied in the lumbar region. Here, like- 
wise, the current evokes flexion of the foot. 

13. Plantar reflex. — Evoked by sinusoidalization of 

« 

the ist and 2nd sacral segments. 

14. Babinski reflex. — If, in the norm, we irritate the 
inner side of the sole of the foot from the heel to the toes by 
stroking with a moderately sharp object, all the toes undergo 
plantar flexion ; but, if the great toe (and perhaps the other 
toes) undergoes dorsal flexion (Fig. 6), the Babinski reflex 
or phenomenon is present. As a rule the latter phenomenon 
indicates a lesion of the pyramidal tract. 

The observations of the author show that the Babinski 
reflex may be elicited in the norm by applying the interrupting 
electrode (large electrode over the sacrum) over the spinous 
process of either the 3d or 4th lumbar vertebra. 

Schneider's explanation of the Babinski reflex is as 
follows; Plantar flexion of the toes (the normal reflex) de- 
pends upon a cortical component of the reflex, whereas dorsal 
flexion of the toes (Babinski reflex) depends on the spinal 
component. If then, there is a lesion of the pyramidal 
tract, the reflex for the plantar flexion is interrupted, whereas 

15 



S p 



n 



t h 



r a p y 



the spinal component for dorsal flexion is retained. In 
several cases with lesions of the pyramidal tract observed by 
the author, and in all of whom the Babinski reflex was present 
by irritating the sole of the foot, the same reflex could not be 
elicited as in the norm by sinusoidalization of the spinal 
column. In these cases, however, the plantar reflex was 
elicited by sinusoidalization in lieu of the Babinski reflex. 



/V RormaL FLexor 





response 



Fig. 6. — ^The Babinski toe-reflex (Hutchison and Rainy). 

which occurs in the normal subject. The latter observation 
would seem to show in part the correctness of Schneider's 
explanation of the Babinski reflex. The occurrence of the 
plantar reflex in these cases suggests that it is likewise a 
spinal and not a cortical reflex and that its occurrence in 
lieu of the Babinski by sinusoidalization is equally diagnostic 
of a lesion of the pjTamidal tract. 

The phj^ician will obser\'e that the spinal muscular 
reflexes (provided the current remains in action for several 
seconds) consist of clonic rather than tonic contractions, and, 
furthermore, that the spinal reflexes may be elicited even 
though the ordinarj' cutaneo -peripheral reflexes are absent. 



lb 



j4natomiCf Topographic and Physiologic Data 

CHAPTER II. 
ANATOMIC, TOPOGRAPHIC AND PHYSIOLOGIC DATA. 

STRUCTITRE OF THE SPINAL CORD — ROOTS AND DISTRIBUTION OP THE 
SPINAL NERVES — LOCATION OF THE SPINAL NERVES — ANATOMIC 
LANDUARKS — SYUFATHETIC SYSTEU — ^PHYSIOLOGY OF THE SPINAL 
CORD — LOCALIZATION OF THE FUNCTIONS IN DIFFERENT SEGUENTS 
OF THE SPINAL COKD. 

A transverse section of the spinal cord (Fig. 7) shows it 
to consist of central gray matter containing nerve-cells and 



K. 




a 



...ji 



Fig. 7. — Illustrating the conducting paths in the spinal cord at the level ol 
the third dorsa.1 nerve. The black part represents the gray matter; V, anterior, 
and HW, posterior root; A, direct, and G, crossed pymmidal tracts; B, anterior 
column ground bundle; C, Coil's column; D, postero-external column; E and F, 
roiled lateral paths; H, direct cerebellar tracts (Landois). 

surrounding white matter made up of nerve-fibers. The 
gray matter is divided into the anterior and posterior horns. 
The SPINAL NERVES take their origin from the spinal cord 
and on either side make their exit through the intervertebral 
foramina. There are 31 pairs of spinal nerves : 

Cervical nerves 8 pairs 

Dorsal " 12 " 

Lumbar " 5 " 

Sacral " 5 " 

Coccygeal " 1 pair 

17 



Spondyloth e r a p y 

ROOTS OF THE SPINAL NERVES. 

The anterior or ventral roots arise from the motor cells 
in the anterior horn of the gray matter and are motor in 
function. The posterior or dorsal roots arise from the 
nerve-cells of the spinal ganglia from which they can be 
traced into the cord and are sensory in function. 




Fig. 8. — A apinal nerve with its anterior and poiteiioT roots (Teatut). i, a 
pottioD of the spinal cord viewed from the left ude; i, anterior meaian fisiurei 3, 
anterior horn; 4, posterior homi 6, formatio reticularis; 7, anterior root; 8, posterior 
root with 8>, its ganglion; 9, spinal nerve; 91, its posterior divi^on. 

On the posterior root of each of the spinal nerves, a gang- 
lion is found which is located in the intervertebral foramen 
external to the point where the nerve perforates the dura 
mater (Figs. 8 and 38). 

DISTRIBUTION OF THE SPINAL NERVES. 

Just beyond the ganglion, the roots of the spinal nerves 
unite to form a trunk which constitutes the sfnnal nerve. 

After the latter passes out of the intervertebral foramen, 
it divides into a posterior division for the supply of the pos- 
18 



Anatomic Landmark 



terior part of the body and an anterior division which supplies 
the anterior part of the body. In each division there are 
fibers from the roots of both nerves. 

Each spinal nerve receives a branch from the sympa- 
thetic (Fig. 9). 




Fic. 9. — Diagnm alter Bobm and Davidoff lo show the composition of a 
peripheral nerve-trunk, i, axon of ganglion-cell; 3, spinal ganglion; j, dendrite of 
gAHglkin-cell; 4, anterior horn of gray matter of spinal cord; 5, axon of motor 
nerve-cell; 6, sympathetic ganglion; 7, axon of sympathetic neuron; 8, nerve-trunk. 

The roots of the majority of spinal nerves pass obliquely 
downwards and outwards to their points of exit from the 
intervertebral foramina, hence the level of their emergence 
from the cord does not correspond to that of their exit from 
the intervertebral foramina (Fig. lo). 

ANATOMIC LANDMARKS. 

There is usually a furrow or medium groove in the back, 
at the bottom of which lie the spinous processes. In 
19 



S p 



t h 



a p y 




Anatomic Landmarks 

emaciated individuals the spinous line replaces the groove. 
The spinal furrow is less evident in the cervical than in the 
lumbar region; in the former situation it is between the 
trapezii and between the larger erector spinae muscles in 
the dorsal and lumbar regions. 

Palpation and definition of the vertebral spinous processes 
are facilitated by directing the patient to lean far forward or 
the processes may be rubbed with the hand, thus evoking a 
spot of hyperemic redness over the tip of each spinous 
process. 

The 5th lumbar spine (marked by a depression) is used 
for measuring the external conjugate diameter of the pelvis. 
The latter diameter from the depression to the upper border 
of the symphysis pubis measures 20J cm. or 8J inches. The 
two posterior superior spinous processes of the ilium are on 
a line with the 3d sacral spine below which lie the sacro-iliac 
joints. 

Petit's triangle is a triangular space corresponding 
to the central point of the crest of the ilium (Fig. 47). 

This triangle is the occasional site of a lumbar hernia and 
is also a convenient region for relieving congestion of the 
kidney by local bleeding. 

Deep pressure made in the neck in the direction of the 
carotid artery and opposite the cricoid cartilage detects a 
tubercle belonging to the transverse process of the 6th 
cen^ical vertebra and is known as chassaignac's tubercle. 
Against the latter the carotid artery may be compressed by 
the finger. 

The VERTEBRAL ARTERY may be compressed in the 
suboccipital region, the thumb and finger of one hand being 
placed in the hollows behind the mastoid process, while 
counterpressure is made by the other hand on the forehead. 
As the arteries lie under the complexus muscle, the pressure 

21 



S p 



I 



t h 



r a p y 



must be rather firm. If such pressure inhibits pulsating 
noises or vertiginous feelings, the inference is that, these axe 
caused by congestion in regions supplied by branches of the 




I 

H showi: 

■ andu 

I basilar artery (Internal ear). If noises in the ear are dimin- 

I ished by compression of the carotid artery, they are prob- 

■ ably caused by congestion in the middle or external ear, and 
I are often synchronous with the pulse. 




L 



a 



n 



m 



a 



SPINES OF THE 
VERTEBRAE. 

Adas. 



Axis. 

4th cervical vertebra. 
6th cervical vertebra. 

7 th cervical vertebra 
{Vertebra prominens) 



2d dorsal spine. 



3d dorsal spine. 



4th dorsal vertebra. 



7 th dorsal spine. 



loth dorsal vertebra. 



1 2th dorsal spine. 
4th lumbar spine. 



LANDMARKS. 

RELATION. 

On a line with the hard palate. The trans- 
verse process is just below and in front of 
the tip of the mastoid process. 

Felt beneath the occiput and is on a level with 
the free edge of the upper teeth. 

Opposite the hyoid bone. 

On a line with the cricoid cartilage. Esoph- 
agus commences. 

Easily recognized, owing to its prominence 
and serves as a guide for counting the proc- 
esses downwards. Location of the in- 
ferior cervical ganglion. 

Corresponds to the head of the 3d rib. The 
scapula covers the ribs from the 2nd to the 
7th, inclusive. The apex of the lower lobe 
of the lung is at the level of the 3d rib behind. 

Corresponds to the inner edge of the spine of 
the scapula. Termination of the arch of 
the aorta on the left side. 

Opposite the junction of the ist and 2nd section 
of the sternum. Thoracic aorta commences 
to the left. Trachea bifurcates midway 
between the 3d and 4th dorsal spines, the 
roots of the lungs thus lying a little below 
and external. 

Corresponds to the inferior angle of the scap- 
ula when the patient is sitting with the 
arms hanging at the side. 

Corresponds to the tip of the ensiform cartil- 
age. Lower edge of lung posteriorly. Car- 
diac orifice of the stomach. 

Corresponds to the head of the last rib. 
Aortic orifice in diaphragm. 

Highest point of the crest of the ilium. The 
umbilicus is near the same plane. Division 
of the aorta. Below the tip of this spine, 
point of election for lumbar puncture. The 
disk of this vertebra corresponds to the 
• ileo-cecal valve. 

23 



Spondyloth 



r a p y 



LOCALIZATION OF THE SPINAL NERVES. 

In the adult, as a rule, the spinal cord extends from the 
lower surface of the foramen magnum to the lower edge of 
the I St lumbar vertebra, and only exceptionally as far as the 
2nd lumbar vertebra. 

The position of the cord shows slight alterations in posi- 
tion in the movements of the body. Thus it rises during 
spinal flexion. The root -origin of the spinal nerves may be 
determined as follows (Consult Fig. lo) : 



For the upper 4 cervical nerves 
subtract i from the number of 
the nerve. 

For the 4 lower cervical nerves and 
upper 6 DORSAL nerves, sub- 
tract 2 from the number of each 
nerve. 

For the lower 6 dorsal nerves sub- 
tract 3 from the number of the 
nerve. 



Thus the root-origin of the 3d 
cervical is opposite the 2nd cer- 
vical spine. 

Thus the root-origin of the 8th 
cervical nerve corresponds to 
the 6th cervical spine. 

Thus the root-origin of the 9th 
dorsal is opposite the 6th dorsal 
spine. 



The LUMBAR NERVES take their origin contiguous to the 
loth and nth dorsal spines and the sacral nerves between 
the nth dorsal and ist lumbar spines. 



the SYMPATHETIC SYSTEM. 

This portion of the nervous system is concerned in the 
distribution of impulses to the glandular structures, cardiac 
muscle and the non -striated muscular tissue of the body. 
While this system is not supposed to be independent in 
action of the cerebro-spinal system, Langley employs the 
term auimiomic to indicate that the efferent fibers of the 
sympathetic are endowed with a certain independence of the 
central nervous svstem. The autonomic fibers are removed 
from the control of the will and preside over unconscious 

24 



■^H 


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■ 




j™^^^, ^H 


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bltt^iltki^dfiiit 


^^^1 


£tmi ommiaiiaAUi 


\j^^ ^^*y/^« ^^^ 




i,tm«,f«i,jBaManliad 






f,«gi-,«0'pcnxvasi. 






To Uani/lum jwtro.ufn > 




^^1 


CtrvicatntTH I - 


J^-^ -Saj^-- 1 


^^^1 




1^^^g^««,«^«. 1 


^H 


'^^ 




^H 


Lx 




^^H 


/ki—t«,^v^iM ^^jn^ 


K^^ ^^V ^^^1 


^^H 


ftkai^^Mds>^i-« lul. VlP 


^\/3f-r'"''" """ ^^ 


^1 


D,^,, Kfr^I^f 


^V''\'' iTw-KftB" »l/^ /i?*i M« 


^^H 


"jI^ 


■VKX -' Vf'l Aifmnt Itmnf-I itrti. 


VH 


j^m 


^ \\^MP%|^'' M/lfi'/'yo'i'y fita. 


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pM^ 


M' ^jKMrr.tfoac piEKVS ^^^ 


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'^ T^J^ 




^■B 


'^ I^ 


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dK 


'?V'"'r"S^Jv» „."*•-'/. ^H 


1 


''^'^t' 


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^^H 


J'S'TS^ 


•V /wffP"'^^' g^^^'-'pM^ 


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ir-^- 


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"^^^W^^^to^fe^ld^ VHn-'^ ] ^ 




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H 


^^5^JnV \ V^C^^^^" 


^ ^' ji 


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r.^^ 


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^1 


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^K^r^^* 


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"^S 


^SKbb^ "^-6^».,../ A«„ V„.. 


^1 


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fr^>i. 


^' ^^^^^^^5^ HIPOGASmc PWiDS 


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c«'jr-'""' 




H 


Fic 7».— rllustraling the principal com municai ions Iwnvetn ihc sympflthMic 


^^^1 


wd cerebn>-«piiial ne 


voussyslem (Flower, modified by Morris). 


1 



Spondylotherapy 

reflexes like intestinal peristalsis, contraction and dilation of 
the arteries and the secretory activity of the digestive glands. 
The sympathetic system communicates with the cerebro- 
spinal system, by means of eflferent and aflferent nerves. 
Fig. 12 shows the principal communications between the 
two systems. 

The sympathetic nerves are now regarded as carrying 
chiefly motor fibers, and their cell-origin is most probably 
the lateral horns on the same side of the spinal cord. 

THE PHYSIOLOGY OF THE SPINAL CORD. 

The spinal cord has a dual function ; it acts as an inde- 
pendent central organ and as a conductor of nervous im- 
pulses. 

Reference will be made primarily to the spinal cord as a 

REFLEX CENTER. 

A reflex refers to involuntary production of activity in a 
part brought about by conduction of a stimulus along an 
afferent (sensory) nerve to the motor cells in the cord or 
medulla. This stimulus is converted into an impulse by 
the motor cells, which impulse is then conducted to a part 
by means of an efferent (motor) nerve. 

The mechanism of the reflex known as the knee-jerk 
is illustrated in Fig. 13. To elicit this reflex, it is neces- 
sary to have an intact reflex arc, otherwise the reflex is 
abolished. The reflex arc is made up as follows : 

1 . A healthy tendon which, when struck with a hammer, 
constitutes the peripheral stimulus which is then conducted 
by- 

2, an afferent (sensory) nerve along the posterior roots 
to the anterior horn of the spinal cord where, by means of 
the motor cells, it is converted into an impulse which is then 
conducted bv means of 

26 



T h 



K 




SHOWING THE MECH«NISM OF THE DEEP 
REFLEKES «ND EXAMPLES OF THE LESIONS 
1 INCREASE OB ABOLISH THEM 
S ILLUSTRATED BV THE KNEE-JERK. 

- LESIONS ABOLISHING 
THE REFLEKES, 

BLACK CmCLes = LE5IONS EUAGGERATING 
THE REFLEXES. 



S p ondylo therapy 

3, an eflferent (motor) nerve to a healtliy muscle. 
The text-books usually describe the following reflexes : 

1. Superficial or cutaneous elicited by irritation of the 
skin or a mucous membrane resulting in contraction of the 
muscles contiguous to the site of irritation ; 

2. Deep or tendon reflexes elicited by striking a tendon, 
muscle or periosteum near the tendon ; 

3. Organic or \nsceral reflexes which result in special 
acts like urination and defecation. 

The reader is referred to page 7, where consideration 
was giveil to the vertebral reflexes. The latter are essentially 
central and are elicited bv concussion or sinusoidallzation of 
the spinous processes of definite vertebrae and by pressure 
at the vertebral exits of the spinal ner\-es. 

A single paradigm may be cited to show the importance 
of the central vertebral reflexes in diagnosis. In locomotor 
ATAXL\ the posterior root -fibers in the posterior columns in 
the lumbar region are involved, in consequence of which 
the knee-jerk* is diminished or usually abolished. 

The knee-jerk would be similarly influenced in lesions 
invohnng the anterior horns of the gray matter by cutting 
off the motor path. In other words, to elicit the knee-jerk 
the reflex arc in the lumbar cord must be intact. Reference 
to Fig. 14 shows that the center for the knee-jerk is located 
in segment III, of the medulla lumbalis and reference to 
Fig. 4, shows that the quadriceps reflex (central vertebral 
reflex) corresponds practically to the same site. 



♦The knee-jerk reSex arc is made up of nerv-^^nbers which |>ass to and from the 
CTureus v,oae of the four muscles wr-«i:u:ini; :he qudvirioeps extensor) by the 
anterior crural ner\e and lo anvi frv»m the har.*.«rir^ by ihe sciatic nen.-e. 
The ner^TS to ihe crun-us arise frv^ni :he sp;r.Ai rervt^nxxs corresponding to 
the ;rd and 4th lunibMr: ihe hanistrinij supi^Iv is frv^ni the >th lumbar and ist 
and 2nd sacral rvxxi. h will Nr nv^e^i tha; cor.usc^^n wiU not elicit the knee- 
jerk. Here it is nevvssan- to sinusoidaliie siniultaiseouslv the 2nd lumbar 
vertebra and the sacral region. 

28 



T h e Knee-Jerk 

Now, in locomotor ataxia, the knee-jerk is abolished, 
owing to involvement of a part of the reflex arc (the afferent 
or sensory path), and when the knee-jerk is elicited in the 
usual way, it may be difficult to say whether any other part 
of the arc in question is implicated. If one can provoke 
the central quadriceps reflex, one can at least conclude that 
the descending paths (efferent or motor) are intact. For a 
like reason a peripheral neuritis may be difficult to differen- 
tiate from locomotor ataxia owing to involvement of the 
peripheral sensory nerves. 

In a number of patients with locomotor ataxia examined 
by the author, a quadriceps reflex was usually present, and 
in a number of instances an exaggerated knee-jerk was 
obtainable on either one or the other leg. Usually it was 
absent in the more atactic leg or in advanced stages of the 
disease. 

Here one was constrained to conclude that when the 
knee-jerk was obtainable, the posterior root-fibers were 
not entirely destroyed. It was also found that the Achilles 
reflex could be elicited (corresponding to segment V of the 
medulla lumbalis, Fig. 14) in a number of cases of loco- 
motor ataxia by sinusoidalization over the sacrococcygeal 
articulation. 

The elicitation of the vertebral reflexes directs reference 
to a mooted point in physiology, viz., whether the tendon 
reflexes are or are not true reflexes. According to the 
prevailing opinion, they are not true reflexes but are due to 
direct stimulation of the muscle itself. The author questions 
the correctness of the latter observation insomuch as a 
veritable Achilles reflex and knee-jerk can be elicited in 
the norm by vertebral stimulation * 

♦The author is convinced that this subject embraces a field of research of vast im- 
portance to the neurologist. Man is available for experimentation for, in the 
study of the vertebral reflexes, they can be evoked with an accuracy almost 
equal to their elicitation by vivisection. 



Spondylotherapy 

^saBBSssBBBBssss^^sssssssss^a^aBBBBsaBaBasi^ss^^^i^ss^^^:s. 

In eliciting the knee-jerk the large electrode must be 
placed over the lower sacral region and the interrupting 
electrode over the spinous process of the 2nd lumbar vertebra 
and one leg crossed upon the other leg. A strong current is 
necessary. With some sinusoidal machines the knee-jerk 
cannot be evoked, but with Kellogg's apparatus (Fig. 44) 
it can practically always be excited. 

LOCALIZATION OF FUNCTION IN THE DIFFERENT SEGMENTS 

OF THE SPINAL CORD. 

A SPINAL SEGMENT refers to the part of the cord contained 
between two sets of roots. E^ch segment must be regarded 
as a unit endowed with motor, sensory, vasomotor, trophic 
and reflex functions with regard to the peripheral distribution 
of the roots of the nerves which emerge from and enter it. 
A segment is called after the ner\'e-roots which take their 
origin from it and not with reference to its relation to the 
vertebrae. 

A diagranunatic representation of the spinal cord is shown 
in Fig. 14. The cord is divided into its four regions. Within 
each region the spinal segments are indicated by numbers. 
On the right-hand side of the diagram, muscles or groups of 
muscles are indicated, and the lines proceeding from them 
pass to the segments of the cord in which the cell-bodies of 
origin are located. 

On the left side of this diagram the sensor}* regions are 
indicated and the lines show their relation to the diflferent 
segments of the cord itself. 

To determine the condition of the cord at different levels 
the following table *^ is ser\'iceable. It shows the different 
segments controlling the skeletal muscles, the reflex centers 
and the chief location of the segmental skin -field. 



30 




FlO 14.— Diagrammatic representation erf the spinal cord showing ihe spinal 
Mginents for inoiion and sensibilily. Jakob, SUrr, Sachs, Dana, Mills and Builcr. 



S p n d y I the r a p y 



LOCALIZATION OF THE FUNCTIONS IN THE SEGMENTS OF THE 

SPINAL CORD. 



Segment 


Striped Muscles 


Reflex 


Skin-Fields 


I, II, and HI 








C 


Spienius capitis 
Hyoid muscles 


Hypochondrium (?) 
Sudden inspiration 


Back of head to 




vertex. 




Sterao-mastoid 


produced by sudden 


Neck (upper part). 




Trapezius 


pressure beneath the 






Diaphragm (C HI-V) 


lower border of ribs 






Levator scapuls (C III- 
V) 


(diaphragmatic). 




IV c 


Trapezius 
Diaphragm 


Dilation of the pupil 
produced by irrita- 


Neck (lower part 
to second rib). 






Levator scapulae 
Scaleni ^C IV-DI) 


tion of neck. Reflex 


Upper shoulder. 




through the sympa- 






Teres mmor 


thetic (C IV-DI). 






Supraspinatus 








Rhomboid 






vc 


Diaphragm 
Teres minor 


Scapular (CV-DI). 
Irritation of skin over 


Outer side (^ 


* ^i^ ••••••••• 


shoulder and up- 




Supra and infra spinatus 


the scapula produces 


per arm oyer del- 




(C V-VI) 


contraction of the 


toid regioiL 




Rhomboid 


scapular muscles. 






Subscapularis 
Deltoid 


Supinator longus and 






biceps. 






Biceps 


Tapping their ten- 






Brachialis amicus 


dons produces flex- 






Supinator longus (C V- 
VII) 


ion of forearm. 






Supinator brevis (C V- 








VII) 








Pectoralis (clavicular 








part) 

Serratus magnus 






VIC 


Teres minor and major 


Triceps. Tapping 


Outer side of fore- 




Infraspinatus 


elbow tendon pro- 


arm, front and 




Deltoid 


duces extension of 


back. Outer half 




Biceps 


forearm. 


ofhand(?). 




Brachialis anticus 


Posterior wrist. Tap- 






Supinator longus 


ping tendons causes 






Supinator brevis 


extension of hand 






Pectoralis (clavicular 


(C \T-\TI). 






part) 








5%erratus magnus (C V- 








viin 








Coraco-brachialis 








Pronator teres 








Tria*ps (outer and long 








heads) 








F.xtenst"»rs of wrist 






1 


(C vi-viin 







^l 



Segmental Localisation 



LOCALIZATION OF THE FUNCTIONS IN THE SEGMENTS OF THE 

SPINAL CORI>— Continued. 



SEGMSNT 


Stkifed Muscles 


Reflex 


Skin-Fields 


VIIC 


Teres major 

Subscapularis 

Deltoid (posterior part) 

Pectoralis major (costal 

part) 

Pectoralis minor 

Serratus magnus 

Pronators of wrist 

Triceps 

Extensors of wrist and 

fingers 

Flexors of wrist 

Latissimus dorsi (C VI- 

VIII) 


Scapulo-humeral. 
Tapping the inner 
lower edge of scap- 
ula causes adduction 
of the arm. Anterior 
wrist. Tapping an- 
terior tendons causes 
flexion of wrist (C 

vii-vni). 


Inner side and 
back of arm and 
forearm. Radial 
half of the hand. 


Vine 


Pectoralis major (costal 

part) 

Pronator quadratus 

Flexors of wrist and fin- 

girs) 

Latissimus 

Radial lumbricales and 

interossei 


Palmar. Stroking 
pahn causes closure 
of fingers. 


Forearm and hand, 
inner half. 


I D 


Lumbricales and inter- 
ossei 

Thenar and hypothenar 
eminences (C VII-DI) 




Upper arm, inner 
half. 






II to XII D . . 


Muscles of back and ab- 
domen 

Erectores spinas (D I- 
LV) 

Intercostals (D I-D XII) 
Rectus abdominis (D V- 
DXII) 

External oblique (D V- 
XII) 

Internal oblique (D VII 
-LI) 
Transversalis(D VII-LI). 


Epigastric. Tick- 
ling mammary region 
causes retraction of 
epigastrium (D IV- 
VII). 

Abdominal. Strok- 
side of abdomen 
causes retraction of 
belly (D IX-XII). 


Skin of chest and 
abdomen in obli- 
que dorso-ventral 
zones. The nipple 
lies between the 
zone of D rV and 
D V. The um- 
bilicus lies in the 
field of D X. 


IL 


Lower part of external 

and internal oblique and 

trans versalis 

Quadratus lumborum (L 

MI) 

Cremaster 

Psoas major and minor( ?) 


Cremasteric. Strok- 
ing inner thigh caus- 
es retraction of scro- 
tum (L MI). 


Skin over lowest 
abdominal zone 
and groin. 



33 



S p n d y I the r a p y 



BB^ 



LOCALIZATIOX OF fHE FUXCTIOXS IX THE SEGMENTS OF THE 

SPINAL CORD— Co N T iXLXD . 



Stufed Mcscles 



SlIN-FkELDS 



n L 



m L. 



I\'L. 



VL. 



I to II S. 



Ill to V S. 



Psoas major and minor 
Iliacus 



(lower part) 
FloDon of knee (Remak) 
Adductor toqgus and bre^ 



Saitorius (lower part) 

Adductors of thigh 

Quadriceps fcmoris 

U-LI\0 

Inner rotators of th%h 

Abductors of th%h 



(L 



Patellar tendon. 
Tapping tendon 
auses extension of 



Fleioisof knee(Fcrrier) iGluteaL StroAuDg 
Quadriceps feawris buttock causes dimp- 



Adductois of th^ 
Abductors of thigh 
Extensors of ankle (tibi- 
alis anticus) 

Ghitet (medius and mi- 
nor) 



ling in fold of 
tock (L R-\-). 



but- 



Flexois of knee (ham- 
slriog muscles) (L I\'-S 

II) 

Outward rotators of thigh 
Glutei 

Flexors of ankle (gas- 
trocnemius and sc^us) 
(L I\'-S II) 

Extensors of toes (L I\*- 
SI) 
Pexonci 



Front of thigh. 



Front and iimer 
of thigh. 



Mainly irmer side 
of thi^and l^to 
ankle. 



Flexors of ankle (L V-S 

II) 

Long flexor of toes (L V- 

SII) 

Peroniei 

Intrinsic muscles of foot 



Foot reflex. Exten- 
sion of .\chilles ten- 
don causes flexion of 
of ankle (S MI). 
Ankle-clonus. PUn- 
tar. Tickling sole 
foot causes flexion of 
toes or extension of 
great toe and flexion 
of others. 



Back of kg 
part of foot. 



and 



] Perineal muscles. Le\*ator -Vesical and anal re- 
and sphincter ani (S I- flexes. 
Ill) 



Back of thigh, leg, 
and foot; outer 
side. 



Skin over sacrum 
and buttock. 
Anus. 

Perineum. Geni- 
tals. 



S e g m e n tat S k i n ■ F i e i d ^ 




Fig. 15. — Showing the areas on both surfaces of (he body which are related to 
thedilferent segments of the spinal cord. When a segmeni of the cord is destroyed, 
the surface o( the body is anesthetic in the area corresponding to that segment. 
C. cervical; D, dorsal 01 thoracic; L, lumbar^ S, sacral. 



Spondyloth e r a p y 

Fig. IS shows the segmental skin-fields which assist in 
determining the segmental level of spinal cord and of 
dorsal root-lesions. 

VISCERO-MOTOR CENTERS. 

It will be noted that the following physiologic location of 
the viscero-motor cells does not correspond with the clinical 
localization of the viscero-motor reflexes (Fig. 5). However, 
the former are cited for the sake of completeness. It will 
also be observed that the clinical evidence tallies with 
physiologic observation, viz., that there is usually a 
double viscero-motor mechanism consisting of excitation and 
inhibition. 

TABLE OF THE VISCERO-MOTOR CENTERS. 

STRUCTURE. LOCATION OF VISCERO-MOTOR 

CELLS. 

Pupil (constriction of). Nucleus of the 3rd cranial nerve. 

Pupil (dilatation of). Between the 6th cervical and 2nd 

dorsal segments. 

Bronchi and bronchioles (constric- Nucleus of the loth cranial nerve, 
tion of). 

Heart (acceleration of). 6th cervical to the 2nd dorsal seg- 

ments of the cord. 

Heart (inhibition of). Nuclei of the loth and nth cra- 

nial nerves. 

Alimentary canal (accelerating Nucleus of the loth cranial nerve, 
peristaltic movements). 

Alimentary canal (inhibition of 4th dorsal to the 2nd lumbar seg- 
peristaltic movements). ments. 

Uterus (inhibition of muscular 2nd, 3d and 4th lumbar segments, 
coat and contraction of the cer- 
vix and vagina). 

Dilatation of cervix uteri and 2nd, 3d and 4th sacral segments, 
vagina. 

Bladder (contraction of the sphin- 2nd, 3d and 4th lumbar segments, 
cter). 

Bladder (relaxation of the sphin- 2nd, 3d and 4th sacral segments, 
cter). 

36 



Relation ofSpines to Segments 

By referring to Fig. lo the physician will be able to 
determine the relation of the segments of the spinal cord to 
the spines of the vertebrae. It may be recalled that a seg- 
ment is called after the pair of nerves which arise from it 
and not from its vertebral relation. The following table 
shows the approximate relation of the spines of the vertebrae 
to the segments of the spinal cord. 

APPROXIMATE RELATION OF THE VERTEBRAL SPINES 

TO THE SPINAL SEGMENTS. 

CERVICAL SEGMENTS. VERTEBRAL SPINES. 

»J \ ist cervical spinous process. 

m \ 2nd cervical spinous process. 

V 3d cervical spinous process. 

VI 4th cervical spinous process. 

-XJJ \ 5th cervical spinous process. 

DORSAL SEGMENTS. 

J: \ 6th cervical spinous process. 

Ill 7th cervical spinous process. 

IV ist dorsal spinous process. 

V 2nd dorsal spinous process. 

VI 3d dorsal spinous process. 

VII 4th dorsal spinous process. 

VIII 5th dorsal spinous process. 

IX 5th dorsal spinous process. 

X 6th dorsal spinous process. 

XI 7th dorsal spinous process. 

XII 8th dorsal spinous process. 

LUMBAR SEGMENTS. 

I . . J 9th dorsal spinous process. 

-JJ \ loth dorsal spinous process. 

IV 1 nth dorsal spinous process. 

SACRAL SEGMENTS. 

TV ^ H V r ^^^^ dorsal spinous process. 

COCCYGEAL SEGMENT. 

I ist lumbar spinous process. 

The vaso-motor apparatus is discussed on page 272. 



Spondylotherap 



B^^^^^BSBBBBSE^Ba^ 



CHAPTER III. 

SYMPTOMATOLOGY. 

EXAMINATION OF THE BACK — ^THE NORMAL SPINE — ^DISEASES OF THf 
SPINE — SPONDYLOGRAPHY — EXAMINATION OF THE MUSCLES OF 
THE BACK — STIFF BACK — MUSCULAR HYPOTONIA — ^PAIN ANP 
TENDERNESS OF THE SPINE — SYMPATHETIC SENSATIONS — ^DERMA- 
TOMES OF HEAD — ^VERTEBRAL PAIN — ^VERTEBRAL TENDERNESS- 
VERTEBRAL PERCUSSION — ^VIBROSUPPRESSION. 

The VERTEBRAL COLUMN subservcs the following objects : 

1. It is the central pillar of the body and supports the 

weight of the head; 

2. It connects the upper and lower s^ments of the 

trunk and gives attachments to the ribs. 

3. It diminishes the effects of shocks conveyed from 

various parts of the body chiefly by means of its 
curves and the elastic intervertebral discs which 
act the part of buffers.* 

4. It is endowed with considerable mobility and fur- 

nishes a solid tube for the spinal cord. 

The MUSCLES of the back and trunk are the only agents 
in supporting the spine erect. When the muscles in question 
are exhausted, relief is involuntarily secured by means of 
rotation and lateral flexion, thus eventuating in the condition 
known as scoliosis. 

THE NORMAL SPINE. 

The normal spine must be studied with relation to its 
CONTOUR and flexibility. Any deviation of the spinous 

•M the height of an individual ^ken in the morning and again at night a decrease 
in the total height of the body of from i to 2 cm. during the dav will be noted. 
Thb fact may be attributedto compressioti of the intervertebiid discs by the 
weight of the body m the erect posture. 

38 



The Normal Spine 

processes from the median plane of the body may be deter- 
mined by marking each spinous process with a pencil while 
the patient stands erect. In the norm the marks represent a 
straight line. The median line of the body is obtained by 
holding a plimib-line behind the patient so that the lower 
end of the line dips into the groove between the buttocks. 
In the norm each marked spinous process will lie imder the 
plumb-line. 

A record may be made by placing crinoline gauze or 
tracing paper on the back through which the spinal marks 
may be seen and thus transferring the marks to the gauze or 
paper. 

The contour of the spine may be determined by means 
of a strip of lead or pure tin thick enough so that it can be 
molded on the spine and still preserve its shape when re- 
moved. The prominent spinous processes should be indicated 
upon it. The curves of the spine thus obtained may be 
transferred to paper for further study. 

Certain curves are constant, viz. : 

1. Forward in the upper; 

2. Backward in the middle, and 

3. Again forward in the lower region. 

These curves are fixed in the adult but may be almost 
annihilated in early childhood by traction in the horizontal 
position. 

In the erect posture a normal individual will show the 
following curves (Fig. 16): 

1. Cervical, the convexity of which is forward. It 

begins at the ist cervical and ends at the 2nd 
dorsal vertebra; 

2. Thoracic or dorsal, the convexity of which is back- 

ward. It begins at the 3d dorsal and ends at the 

39 



Spondyloth 



r a p y 



BBEB^ 



1 2th dorsal vertebra; its most prominent point 
behind corresponds to the spine of the 7th dorsal. 

Lumbar, which is convex anteriorly, commences at 
the middle of the last dorsal vertebra and ends 
at the sacro-vertebral angle. This curve is more 
marked in the female than in the male. 

Pelvic, which is concave anteriorly, commences at 
the sacro-vertebral articulation and ends at the 
point of the coccyx. 




Fig. 16. — Normal vertebral curves and divisions of the spine (Whitman). 

The average length of the spinal column in the male is 
about 2 feet and 4 inches and the female spine is about 2 feet 
in length. The length of the individual parts is as follows : 

1. Cervical 5 inches 

2. Dorsal 11 " 

3. Lumbar 7 ** 

4. Sacrum and coccyx 5 ** 

40 



The Normal Spine 

In the adult many causes, notably occupations, cause 
variations of the normal contour of the spine, but in children 
such variations may be regarded as abnormal. 

The normal contour results from balancing of the body 
in the erect posture, and if there is any* variation in one part 
compensation induces a change in another part, eventuating 
often in a complete reversal of the normal spinal curves. 

Even in the norm there is a slight lateral convex curve 
to the right, extending from the 5th dorsal to about the 3d 
lumbar vertebra, which has been attributed to the following 
causes: 

1. Aortic pressure on the vertebral bodies; 

2. Excessive use of the right side of the body; 

3. Right-handedness. 

The FLEXIBILITY of the human spine is largely dependent 
on movements between the spine and the pelvis and the 
head. 

It is evident that exercises destined for the spine only 
must presume pelvic fixation, for otherwise, as Lovett" puts 
it, "Part of the muscular force is used in displacing the pelvis 
to the opposite side to balance the body and the movement, 
becomes a general and not a spinal one." 

The MOVEMENTS of the spine are : 

1. Flexion; 3. Lateral flexion; 

2. Extension; 4. Rotation. 

In FLEXION, or forward -bending, if extreme and perfect, 
the spinous processes will describe the arc of a circle and the 
distance by measurement from the 7th cervical vertebra to 
the sacrum is greater than a like measurement secured in 
the erect or prone posture. 

In EXTENSION, or backward -bending, the movement is 
chiefly limited to the lumbar and the last two dorsal verte- 

41 



S p 



t h e r a p y 



bne. In hyperextension, if measurement is made of the 
distance from the 7th cervical vertebra to the sacrum (over 
the spinous processes), it is decreased when compared with 
a like measurement in the erect posture. 

Lateral flexion may be tested by side-bending in the 
erect posture. In the norm the movement is located at and 
below the lumbar dorsal junction. 

Rotation is most pronounced in the erect posture in the 

"^ T^ Cum 




TRANSMITTED AORTIC PULSATIONS DORSAL RECION 

Fio. 17. — Spondylograms reduced one-half. A, taken at the level of the 7th 
cervical spine; B, taken in the dorsal region; C, taken in the lumbar region; D, 
transmitted aortic pulsations taken in the dorsal region during the time the patient 
iusiwnds respiration. 

cervical and dorsal regions ; the maximum is attained at the 
lop of the cervical column extending below to the lower 
dorsal region where it is no longer evident. 

SPONDYLOGRAPHY. 

It is generally contended that the spinal column enjoys 
a considerable range of motion as a whole, but that the 
motion Ix^tween any two individual pieces is extremely 

42 



S p 



g 



p h 



limited. It is known that during deep respiration a straight- 
ening of the vertebral column occurs involuntarily. The 
author has reason to believe that the vertebrae enjoyagreater 
degree of motion than is usually accepted and to prove this 




Fic. l8. — Apparatus for Uking a spondj'loKTa.ni. 
is adapted for uiking tracings of the abdominal aorta. To take a spondylogmr 
the patient musi be in the prone position. A, stand with an adjustable rod, B; 
C, lever; D, tambour for recording. To the short end of lever (C), a string is 
passed through an opening and the end of the string is fixed by adhesive plaster 
to a spittous process. 

contention the accompanying spondylograms are submitted 
(Fig. 17)- 

They were obtained with the patients in the prone 
posture during quiet breathing. The serrations noted in 
43 



S p n d 



I 



a p y 



the tracings are probably transmitted aortic pulsations. The 
apparatus (Fig. i8) employed for eliciting the spondylo- 
grams was originally constructed by the author for taking 
tracings of the abdominal aorta." 

Spondylography will aid in the early diagnosis of respir- 
atory vertebral immobility and by furnishing a permanent 
record, the course of a vertebral disease may be accurately 
controlled. Here we are in the possession of a method which 
may be as important to the orthopedist as is the sphygmo- 
graph to the clinician. ^| 

DISEASES OF THE SPINE. 1 

SPINAL EXAMINATION FOR DEFORMITY. 

With the patient in the erect position (heels together and 
arms hanging) note if the curves are normal or if there is 
any abrupt projection of one or more spines. 

Any ROTATION' of the vertebrae may be determined by 
comparing the prominence of the angles of the ribs, the trans- 
verse processes of the lumbar vertebne, the height and 
prominence of the scapula and the prominence of the iliac 
crests on the two sides. Estimation of rotation or twist is 
best determined by Adam's position: The patient bends 
forwards (with unflexed knees) until the trunk is horizontal 
with the hands hanging doi^-n. With the head on a level 
with the spine the physician notes whether either side of the 
trunk is more prominent upward. The presence of an up- 
ward prominence indicates rotation or twist. Next, the 
anterior aspect of the body is inspected and the following 
noted with reference to the two sides of the body ; deformities 
of the chest and the level of both anterior iliac spines. Again, 
inspecting the back, the patient is instructed to bend forward 
(with knees straight) and note should be made if he bends 
freely and straight forwards. If the movement, however, is 



Examinati 



n 



for D efo r m i ty 



restricted and oblique and if the angles of the ribs are un- 
covered by the scapulae and project more on one side, one 
is dealing with signs of rotation of the spine. The 
presence and degree of this rotation determine the diagnosis 
of Scoliosis and not, as Gould*' emphasizes, the lateral 
deviation of the tips of the spinous processes. Next, the 
patient assumes the prone posture on a flat couch. In the 
latter position the following may Ifc noted : 



CURVES. 

Natural curves lost and replaced 
by a general convexity of the 
spine backwards altered by 
movement and disappearing in 
the recumbent posture. 

The general convexity of the spine 
backwards is permanent and im- 
influenced by movement or the 
recumbent position and the 
movements of the spine are 
diminished. 

There is an abrupt curve of the 
spine backwards or several spin- 
ous processes are projected pos- 
teriorly. 

Diminution of the natural curve in 
the dorsal region with straight 
dorsal spine sunk in between the 
scapulae and rotation of the 
spine. 

Lateral deviation of the spines 
without rotation and disappear- 
ance of the deviation in the re- 
cumbent position. 

A permanent (uninfluenced by 
position) long sweeping curve to 
one side without rotation of the 
vertebrae. 



AFFECTION. 

Spinal muscular debflity from 
rickets or other causes and in 
convalescents who have main 
tained the horizontal posture. 

Spondylitis deformans. 



Caries of the spine (Pott's disease). 



Lateral curvature of the spine 
(scoliosis) . 



Weak-spine often present in hys- 
teria. 



o 



Retraction of chest observed in 
pleuritis and empyema. 



45 



Spondylotherapy 



EXAMINATION OF THE MUSCLES OF THE BACK. 

"The spine lies at the back of a more or less cylindrical 
muscular tube of which the abdominal muscles form the 
front" (Lovett''). 

There are two kinds of muscles directly attached to the 
back, one group passing from one part of the spine to another 
part and to the head and another group running from the 
spine to the pelvis or shoulder girdle. 

In diagnosis and in treatment by muscular exercises^ the 
fact must be emphasized that the spinal movements are not 
affected by an individual muscle but by all the spinal muscles 
which act in unison. 

The relative rigidity of the thoracic spine is dependent on 
the attachment of the ribs behind, between two vertebrae 
and to the sternum in front. 

There are two feeble and movable parts of the spine 
(points where important muscles have a dividing line), viz. : 

1. At the cervico-dorsal junction; 

2. At the dorsolumbar junction. 

The ligaments of the spine are loose and the surfaces of 
the articular processes are only in slight contact, hence the 
muscles of the back and trunk are the only agents for main- 
taining the spine erect. The moment the muscles are ex- 
hausted some relief is obtained by rotation and lateral flexion 
of the spinal column (which tightens the ligaments and 
brings the articular processes in closer contact) which 
eventuates in scoliosis. 

RIGIDITY OF THE SPINAL MUSCLES. 

The condition of the spinal muscles may be determined 
by the movements of the patient and by palpation. The 

46 



Spinal'Mu 



HB 



former may be tested by directing the subject to jmnp, run, 
walk, pick up objects from the floor, etc. 

The tests must include movements which necessitate 
flexion, extension and lateral bending of the spine. 

By placing the palm of the hand on various parts of the 
spine and then directing the patient to make different 
motions, one may note during execution of the latter whether 
the vertebrae move or are fixed. 

Special movements exclude definite joint -involvement. 

Free and painless nodding of the head excludes implica- 
tion of the occipito-atloid joint. 

If the face can be easily turned from one side to another 
the atlo-axoid joint is not involved. 

The lower cervical spine is not implicated if flexion of 
the head can be executed freely and painlessly. 

The various voluntary movements must be adapted to 
the intelligence of the patient. Thus children who resist 
passive movements on a table will submit to manipulation in 
the arms of the mother. 

A child will walk toward its mother and will incline the 
head in the direction of the latter — a useful test in determining 
the condition of the cervical spine. 

By placing the patient in a recumbent position (with 
head slightly elevated), first on the right and then on the 
left side, the spinal muscles are relaxed and may be care- 
fully palpated. 

In the norm the muscles show no tenderness, are elastic 
and easily roll under the palpating finger. 

SPASM OF THE SPINAL MUSCLE. 

By the term "5^a5w," one refers to an abnormal muscular 
contraction due to an augmented reaction of the motor nerves. 
When the muscular contraction is prolonged it is known as 

47 




a tonic spasm, in contradistinction to a clonic spasm, in 
which contractions of brief duration alternate with flaccid 
conditions of the muscle. 

Spasm of the spinal musculature such as the author con- 
ceives the condition must be dissociated by the reader from 
the conventional twitchings and spasmodic movements of 
individual muscles or groups of muscles. 

It is true that, the clinician has long recognized the almost 
intelligent function of muscles whether displayed in fixing a 
diseased joint or spine, or in protecting an inflamed serous 
membrane, but he has neglected to carefully palpate the 
spinal musculature for localized spasms which are usually 
tonic in character. 

To detect such muscular contractions the patient must 
be placed on a table in the lateral posture to secure muscular 
relaxation. 

The investigations of the author show that pressure at 
the vertebral exits of the spinal ner\'es will elicit muscular 
contractions in definite regions, and conversely, that pressure 
in the latter situations will evoke localized clonic or tonic 
spasm in definite spinal regions. 

In disease the peripheral localized spasm may be present 
independent of the spinal spasm, but, as a rule, careful 
palpation of the spinal and peripheral musculature demon- 
strates that they coexist. 

In the accompanying illustration (Fig. 19), the author 
has endeavored to present a composite picture as obtained 
in the norm. 

The illustration shows the vertebral area involved 
spasm during the time firm pressure is made in definil 
peripheral regions. Pressure made at these vertebral exits 
will provoke spasm of the peripheral musculature. The verte- 
bral areas are only approximately correct insomuch as tl 
48 



ed 



S p 



n a 



M 



u 



spasm of the spinal musculature is often diffused and exact 
localization is often impossible. The palpating finger may 
only feel a tremor or a sensation like a pulsation in the 
muscle. Not infrequently the contraction of the spinal 
muscle may be seen. 

It will be noted that although pressure is only made on 



N£CK 



CI*tST . . , 



CPiGASTftlCr/W 




\9iim^m 



TW/&H 



Fig. 19. — Vertebral areas involved in muscular spasm when different periph- 
eral regions are firmly compressed or irritated. 

one side of the spinal column the muscular contraction is 
often bilateral. If deep and firm pressure with the fingers 
of one hand is made on any of the peripheral points of 
spasm, the other hand will usually detect bilateral localized 
spasm of the spinal musculature corresponding to the 
vertebral areas indicated in Fig. 19. 

While mere cutaneous irritation will induce contraction 

49 



of the spinal muscles, the latter is less evident than when 
deep pressure is made on the peripheral muscles or when 
the peripheral area is painful. The recognition of these 
peripheral and spinal spasms is destined to be of considerable 
value in diagnosis. 

Space will not permit the author to descant further on 
this subject, but he may be permitted to cite meningismus as 
a paradigm. 

The latter affection occurs in association with suppurative 
diseases of the middle ear in children and adults and symp- 
toms are present (notably rigidity of the neck-muscles) 
which simulate disease of the brain although no intracranial 
inflammation exists. 

If the peripheral source of irritation can be inhibited by 
means of cocain, the rigidity of the neck-muscles will subside 
temporarily. Reference to the accompanying illustration 
(Fig. 20) shows the extensive anastomoses of the cervical 
plexus and explains the frequency (when sought) of rigidity 
of the neck muscles in affections of the head and face. 

There must also be a spasm of the spinal musculature as 
an expression of visceral disease and this is a subject worthy 
of investigation. 

At present, however, we must rely on vertebral tenderness 
and the dermatomes of Head as indices of visceral disease 
(page 58). 



STIFF BACK. 



by: 



Stiffness and lack of mobility of the back may be cai 

Pain (lumbago, vertebral disease, tonic spasm of the 

muscles) ; 
Ankylosis of the vertebral column. 



LUSe^^ 



Muscular rigidity is one of the earliest signs of Pott's ■ 
disease and persists until cure is effected. 



1. It is most pro^H 



J C e r V 


C i: 


t I P 


I e ^ 


"^ 


4 


/ 






1 


/ ^^ . 


n^ 








f \ ^' ^^ ' 


^Jf 






^^^^^^^H 


■ ^^''^^^laJI^ 


^ 






^ 


/ jvj 








7>.4«<^ ^1 


u ^^ 


^ 




^- X. 


.auA^tx^CiA 


1/ /^ 


^ 




> 


= ?*.^-^ 


I"? Js''^ S'*'* 


|V 


^Site 


^ 


^H 


rf/ 


^ 


fe- 




4 


f /^ "^^ 


J 






^ 




f 


^ 


K 


j 


k. 


.--Plan of ihc cervical plexus 


(Gnrt- 


J 



S P 



d 



t 



r ' P J 



ntninrcd In the nciKhborhuod of tbe disease, bat soET'-EKiid 
anm- 'li-ttantc. If the patient is (iirected to bene ia r uaj j 
.iriil MM tt)4ti)ity nur spasm is associated wrth doe a njw a am 
.kinl Uii- iiiitlinu of the spinal curre is even and 3oc "mAsn. 
I'olt-. ilistiiw inuv !« sttfdy excluded. 

Miisi iilar riKrdity 'ii»iKK:iutcd with spinal (fecKt ^tsais 
iitoiioit only ill ihv ilimttdtu <lin»:tly 'ippoeed bv t^ cod- 
ifniHiitiol Die rntiimk'^. If ihv spasm, huwevm-. 5 2isoC£3ed 
Willi .|iuiiil i|tti-itw it iT!«i^t9 inutiun in all directioiE- 

\ .till hill k <lii(.- Ill iiitkyl(>!*i» of the verteinai cobnm KIT 
1,. , ■inifl ''v iitv 111 Ihv liilIowiiiK 'liisvascs f^. r. .: SpcxxJr- 
lilm, I'mII -. .H"*ii!*i-. i'(iinly)>i!..iKitaii» and arthritis d 



iivnn-iiNiA. 

itivanuhle si^n uf Deuzasdmiia. 
I'wciitiuily ))y the coDsampoan 
iilm^iioii and the ^torine np in 
< piinliuf^l liy its own autiriiv. 
r iliHii oihvpt, owing to the bet 
niitxtMt' Icr the fatigoe in the 
.11- innitiulalf mure easthr. 
■nimtlv irttiovcs the evidence ol 
•ixx-rXx-. t>itnli(L'ty are washed iniD 



I'litiMv iitui It» origin in the 



Muscular Hypotonia 

act of volition rather than by that of the muscles themselves. 
The very moment these centers are exhausted the contraction 
of the muscle gives way. 

Volition can be fatigued when exerted in imagination as 
well as in actual muscle-eflfort. 

Backache, or a sensation of weariness, is a frequent 
symptom of neurasthenia and the older writers referred to 
this sign as spinal irritation {yide neurotic spine). It is 
known that when fatigue -signs are exaggerated they become 
painful and are described as "aches." 

Many cases of backache in neurasthenics are caused 
by a faulty spinal attitude. Thus the attitude of chil- 
dren with round shoulders (page 96) will substitute lig- 
amentous for muscular support. All our muscular groups 
are not equally and symmetrically developed and many de- 
formities such as spinal curvatures, round shoulders, etc., 
bear witness to the truth of the foregoing statement (vkfe 
Exercises). 

Decrease in the normal tone or elasticity of the muscles 
is designated by the word hypotonia, and this condition is 
frequent in many nervous diseases. 

It is diflBicult to measure muscular-force. The dyna- 
mometer and the ergograph yield valuable but inconstant 
information. 

The muscles may be tested by noting the strength of 
the Galvanic current (read in milliamp^res) and Faradic 
current (measurement on the scale of the secondary spiral 
and expressed in millimeters of coil-distance) necessary to 
produce the minimal contraction. 

The muscles of the healthy side may be used as a standard 
of comparison, otherwise we must be governed by the re- 
actions observed in the average individual with normal 
musculature. 

53 



One notes that when the muscles are weak, with the 
strongest current the contraction of the muscles may be no 
greater than with weak currents. 

The implicated muscles do not contract in tola, but only 
a few bundles contract and appear as slightly prominent 
ridges. 

The Faradic current provokes no tetany, but only several 
clonic contractions of the muscle -substance which succeed 
each other during the closure of the current (myoclonic 
contractions). 

For strengthening defective spinal muscles the sinusoidal 
current (page 151) is very effective. 

Very frequently individual muscle-groups are involved in 
hypotonia. Thus a faulty position of the scapulte may be 
caused by the muscles which maintain the position of the 
latter. Similarly, scoliosis may be provoked by an heredi- 
tary hypotonia of the spinal muscles. 

A lack of tone or relaxation of the muscles is an early 
sign'* of LOCOMOTOR ATAXIA. This hypotonia may be 
estimated as follows: With the patient in the erect position 
the distance from the floor to the greater trochanter and the 
7th cervical vertebra is measured. If the patient is now 
instructed to bend forward (knees stiff) as far as possible 
and the distance in this position is again estimated from the 
floor to the 7th cervical vertebra, it mW be found that in 
health, and in all affections (excepting tabes), it is impossible 
to bend the trunk sufficiently forward to permit the 7th 
cer\'ical vertebra to be brought to or below the level of the 
trochanter. The hypotonia of the muscles in tabes, however, 
permits the vertebra in question to attain a distance of 21 
or more cm. below the level of the trochanter. 





Patn- Perception 



PAIN. 

Pain results from powerful stimulation of a nerve, and 
in accordance with the law of eccentric projection, it is a 
matter of little moment which part of the nerve is stimulated, 
the perception of pain being referred to the periphery. 

According to the prevailing hypothesis pain-perception is 
the result of individual stimulations which accumulate prob- 
ably in the cells in the posterior part of the gray substance 
of the spinal cord and it is the total of such stimulations 
which eventuates in a discharge which the patient interprets 
as pain. 

The intensity of the pain is determined by the duration 
and amount of the stimulation and by the irritability of the 
nerve-fibers and ganglion-cells. 

The expression of pain is no measure of its intensity. 
Animals as well as men show differences in their sensitiveness 
to pain. A frequent clinical error is to underestimate the 
intensity of pain and to question its reality simply because 
by diverting the attention of the patient the latter exhibits 
less evidence of his suffering. 

Pain is usually worse at night for the very evident reason 
that in the daytime our attention is distracted. 

It is also evident that the imagination of pain will accen- 
tuate its intensity. In estimating pain objectively the per- 
sonal equation must always be taken into consideration, and 
by aid of the following method** one may determine the 
degree to which an individual is sensitive to pain. With 
the thumb, pressure is made over the styloid process in the 
neck. Some patients will complain of the slightest pressure, 
whereas others will tolerate considerable pressure without a 
pain-reaction {vide vertebral tenderness on page 71). 



55 



S p n d y I 



t h 



a p y 



REFLEX PAINS. 

As a rule the site of pain corresponds to the location of 
the lesion. In other instances peripheral pains may be 
caused by diseases of the spinal cord. Reflex or transferred 




:rebro-spinal strands ot 



pains may be caused by an irritation at the originof thenerve- 
trunkandthepainmaybereferredtoitsperipheraldistribution. 

The illustrations of Dana (Fig. 21) show the usual 
location of transferred pains. 

Dana observed that the sensory nerves of these areas 
56 




Sympathetic S e n s a t i 



n s 



were correlated with the sympathetic ganglia innervating the 
areas in question. 

SYMPATHETIC SENSATIONS. 

Quincke has collected a number of sympathetic sensations 
associated with a circumscribed hyperalgesia of the skin, and 
one is constrained to conclude that the skin-areas are sup- 
plied by the same nerves as the organs. 

According to Donaldson the splitting nerve-fiber sends 
one portion to the organ and one to the skin overlying it. 

A pertinent illustration of cutaneous hyperalgesia is ob- 
served in affections of the heart when pressure of the skin 
over the heart -region elicits sensitiveness. 

As a rule the skin overlying an organ is associated with 
it reflexly, and it is for this reason that one can explain how 
percutaneous therapeutic methods may influence visceral 
disease. 

SYMPATHETIC SENSATIONS. 



Affection. 

Disease of the middle-ear and 

mastoid process. 
Disease of the frontal sinus. 
Irritation of the pyosterior wall of 

the auditory canal. 

Pxilmonary abscess (percussion of). 
Angina pectoris. 
Diseases of the stomach. 
Intestinal worms. 
Diseases of the liver. 
Diseases of the spleen. 
Diseases of the bladder. 

Diseases of the uterus. 
Coxitis. 



Sympathetic Sensations. 
Parietal pains. 

Trigeminal pains. 

Tendency to cough (irradiation 

from the auricular branch of 

the vagus). 
Pain in the larynx. 
Pain in the left arm. 
Pain in the back. 
Tickling in the nose. 
Pains in the shoulder. 
Pains in the left shoulder. 
Pains in the genitalia and lumbar 

region. 
Pain in the epigastrium. 
Pain in the knee. 



57 



S p 



P y 



DERMATOMES OF HEAD. 

■ While cutaneous pains are usually projected with great 
accuracy to the point stimulated, pain originating in the 
internal organs is located very inaccurately. 

Head" and others have demonstrated that the different 
visceral organs bear a definite relation to certain areas of 
the skin, in other words, in visceral disease,* pain and dis- 
turbed sensation may be referred to definite cutaneous areas. 
Thus one may have a cutaneous expression of visceral disease j 



— Illustrating 




tenderness and the mdialion c 



which I may call an endogenctic skin reflex. The cutaneous 
tenderness in visceral disease is explained as follows : When 
a stimulus is applied to an organ or tissue with diminished 
sensibility and which is centrally connected with an organ 
or tissue with a higher degree of sensibility, pain is referred 
to the organ or tissue which is relatively more sensitive. J 
Reference to Fig. 22 will elucidate this matter. I 

*Kast and Mdlzer." found in animal experimentation that the sense of pain Is 
present in normal organs, and that it ia considerably augmented in inflamed 
organs, and that a subcutaneous or intramuscular injection of cocain is capable 
of completely abolishing the sensation in normal as well as in inflamed organs. 
They suggest that Ihe anesthesia of the abdominal organs observed by some ^ 



ts due to the u«e of ci 



58 



D 



m a t m 



If the viscus is irritated, say as the result of inflammation, 
sensory impulses which are usually below the threshold of 
consciousness are conveyed to its sensory center or segment 
in the spinal cord. Now to the same segment is also con- 
nected a definite area of skin from which sensory impressions 
are habitually received, hence the sensations in consciousness 
are not referred to their true visceral origin but to the surface 
of the body. 

Now Head found that in many visceral diseases, if the 
sensitiveness of the skin were tested by running a pin point 
over the cutaneous surface, definite areas could be demon- 
strated showing hypersensitiveness (hyperalgesia) to pain. 
Such areas on the surface of the body are known as skin- 
units or dermatomes. The latter correspond to the spinal 
segments, from which the posterior roots take their origin and 
not to their peripheral distribution. 

The dermatomes are hypersensitive to heat and cold, but 
not to touch. Head concluded that when the dermatomes 
could be demonstrated they invariably indicated an affection 
of the organ to which they corresponded. The dermatomes 
or zones of hyperalgesia appear early and continue through- 
out the course of a visceral disease. If absent, say in ap- 
pendicitis, they appear after palpation of the appendix. The 
author has found that if the zones are present they are 
practically always exaggerated after manipulation of a given 
organ. 

As a rule the disappearance of a zone is associated with 
relief of a diseased organ. If, however, the symptoms in- 
crease or persist, the sudden disappearance of a zone is a 
sign of ill -omen.** 

There is no definite relation between the severity of the 
visceral lesion and the degree of cutaneous hyperalgesia. 
The absence of a zone does not exclude a lesion of a given 

59 



S p 



d y I t h 



a p y 



organ, but, if demonstrated, it is corroborative evidence that 
such a lesion is present. 

It is important to remember that counterirritation over a 
zone of hyperalgesia is often surprisingly efficient in relieving 
the pain and underlying condition of the visceral disease. 

The application of cold to the abdomen in acute abdom- 
inal affections owing to the anesthesia produced is eqi 
efficient. 

On the same theory Elsbei^ and Neuhof," secure 
from pain in acute affections by anesthetizing the hypei 
esicareawith menthol (50 per cent). 

Reference to Figs, 23, 24, 25 and 26 shows, according 
Head and Schmidt,'^ the segmental distribution of referred 
pain and cutaneous tenderness in visceral disease, and Fig. 27 
shows the associated painful areas about the head relal 
to visceral disease and areas of referred pain and tendei 
in affections of the head and neck. 

METHODS FOR EUCTTING THE DERUATOHES. 

Head tested the skin sensitiveness to pain by pinchi 
up folds of skin or by stroking the skin with the point of a 
sharp pin. 

I often employ the vibrations of a tuning-fork for demon- 
strating the zones and the vibration-sensation may either be 
increased {h\'peralgesia) or diminished (hypalgesia). 

The method of Elsberg and Neuhof* is as follows: 
sharp pin is held between the thumb and index finger of 
the right hand, the nail of the index finger resting on the 
patient's skin. The pin is then made to traverse slowly the 
surface of the skin, care being taken that the nail of the index 
finger presses equally along the area examined. The patient 
must say "now" the moment the stroke of the pin becomes 
paioful. 

60 



dom- 
iual^_ 

ngtS 
erred 
ig. 27 
Jate^H 

:meai^H 

chin^* 



t^l 




f ics. 3J and 34. — Sensory areas of Ihc skin acrording to Bead. Anterior and 
ponerior views. C, cervical; D, dorsal; L, lumbar segments trf the cord. Further 
description of these and subsequent figures on page 6a. 



S p 



ndylotherapy 



SEGMENTAL DISTRIBUTION OF REFERRED PAIN AND TENDER- 
NESS IN VISCERAL DISEASE. 

See Figs. 23, 24, 25 and 26. 

Heart, — ^Third cervical and first, second and third dorsal segments. 

Lungs, — ^Third and fourth cervical and first to ninth (sometimes tenth) dorsal 
s^ments, especially the third, fourth and fifth. 

Breast, — Fourth and fifth dorsal segments. 

Esophagus. — Fifth, sixth and eighth dorsal segments. 

Stomach. — ^Third and fourth cervical and sixth, seventh, eighth and ninth 
dorsal segments. Cardiac end from the sixth and seventh and the pyloric end 
from the ninth. 

Intestines. — Down to the upper part of the rectum: Ninth, tenth, eleventh 
and twelfth dorsal segments. Rectum: Second, third and fourth sacral segments. 

Liver and Gallbladder. — Seventh, eighth, ninth and tenth dorsal segments 
and perhaps the sixth. 

Kidney and Ureter. — ^Tenth, eleventh and twelfth dorsal segments. The 
nearer the lesion lies to the kidney the more is the pain and tenderness associated 
with the tenth dorsal segment. The lower the lesion in the ureter the more does 
the first lumbar segment tend to appear. 

Bladder. — Mucous membrane and neck of the bladder: First, second, third 
and fourth sacral segments. Over-distention and ineffectual contraction: Eleventh 
and twelfth dorsal and first lumbar segments. 

Prostate. — ^Tenth, eleventh and twelfth dorsal, first, second and third sacral 
and third lumbar segments. 

Epididymis. — Eleventh and twelfth dorsal and first lumbar segments. 

Testis. — ^Tenth dorsal segment. 

Ovary. — Tenth dorsal segment. 

Uterine Appendages. — Eleventh and twelfth dorsal and first lumbar segments. 

Uterus. — In contraction: Tenth, eleventh and twelfth dorsal and first lumbar 
segments. Os uteri: First, second, third and fourth sacral segments, and very 
rarely, the fifth lumbar. 



62 



D 



trmatomes 




Figs. 35 and 16. — Senaory areas of the skin according to Head. 



Spondylotherapy 



ASSOCIATED PAINFUL AREAS ABOUT THE HEAD RELATED TO 

VISCERAL DISEASE. 

See Fig. 27. 



AREA ON BODY. 



Cervical 3 and 4 

Dorsal 2 and 3 
Dorsal 4 
Dorsal 5 
Dorsal 6 
Dorsal 7 
Dorsal 8 

Dorsal 9 

Dorsal 10 



ASSOCIATED AKEA 
ON HEAD. 



Fronto-nasal 

Mid-orbital 

Doubtful 

Fronto-temporal 

Fronto-temporal 

Temporal 

Vertical 

Parietal 

Occipital 



ORGANS IN PARTICX7LAR RELATION 
WITH THESE AREAS. 



Apices of lungs, stomach, liver, 

aortic orifice (?). 
Lung, heart, arch of the aorta. 
Lung. 

Lung and occasionally the heart. 
Lower lobe of lung and heart. 
Bases of lungs, heart and stomach. 
Stomach, liver and upper part of 

the small intestine. 
Stomach and upper part of the 

small intestine. 
Liver, intestine, ovary and testicle. 



AREAS OF REFERRED PAIN AND TENDERNESS IN AFFECTIONS OF 

THE HEAD AND NECK. 

See Fig. 27. 



ORGAN INVOLVED. 



Ciliary muscle 
(Disorders of 
accommodation) 

Cornea 



Iris 



Vitreous body 
(Glaucoma) 
Retina 

Tympanic mem- 
brane 
Middle ear 



MAXIMUM POINT 

OF REFERRED PAIN 

AND TENDERNESS. 



Mid-orbital 



Frontonasal 



Fronto - temporal, 
temporal, and 
maxillary 

Temporal 

Vertical 

Hyoid 

Vertical and be- 
hind the ear 



ORGAN INVOLVED. 



Upper teeth 
Lower teeth 



Tongue, anterior 
part 

Tongue, lateral 

part 
Tongue, posterior 

part 
Tonsil 

Nose, olfactory 
portion 

Nose, respiratory 
portion and pos- 
terior nares 

Larynx 



MAXIMXTU POINT OF 

REFERRED PAIN 
AND TENDERNESS. 



Frontonasal, nasolabial, 

temporal, maxillary, 

or mandibular. 
Mental, hyoid, superior 

laryngeal and in the 

ear. 
Mental. 



Hyoid, superior laryn- 
geal and in the ear. 

Superior laryngeal, hy- 
oid, occipital 

Hyoid and in the ear. 

Frontonasal and mid- 
orbital. 

Nasolabial (occasion- 
ally). 

Superior and inferior 
laryngeal (in destruc- 
tive lesions). 



64 



a 



n f u I A 



a 




c 



2 



c 



— c 

e- 

> JB 
O ^ 

-Jb 
♦- c 

l2 

•a g a> 

. 2.2 

1-1 4, a, 

LX^ «»« (IM 

OT3 



65 



Not infrequently, if the hyperalgesia is pronounced, the 
patient will scream as soon as the border of the zone is 
reached. Young children cannot give correct answers, 
lience with them this method is useless. The zones of 
hyperalgesia extend from the median line in front to the spines 
behind. 

In Figs. 28 and 29 (Elsberg and Neuhof ), the maximum 
areas of sensitiveness within the boundaries of a zone are 
deeply shaded. 

VERTEBRAL PAIN. ^M 

This symptom may be determined in a variety of ways^" 

1. By pressure of the vertebral spines with the fingers 
or by percussion of the spines by means of the plexor and 
pleximeter (Fig. 2). The latter method is preferable. Very 
frequently no pain is eUcited when a vertebral spine is 
pressed downward, yet, when the spine is pushed to one side 
or lifted, sensitiveness can be demonstrated. 

2. By pressure alongside of the spine at points corre- 
sponding to the exit of the spinal nerves. 

3. By pressure vertically down through the spine made 
on the head and again on the shoulders, 

4. By firm pressure on the transverse processes so as to 
rotate the individual vertebrje and thus determine implication 
of the joints. 

5. By aid of the hot -sponge test .which consists of passing 
down the spine a sponge wrung out in warm water. The 
latter must only be sufficiently warm so as not to be unpleas- 
ant to the healthy skin. In definite affections, notably my- 
elitis, pain is experienced by the patient when the sponge 
passes over the site of the disease. 

6. By testing pain*susccptibility (pallesthesia). In the 
nonn, if a C (130 vibrations) or an A (440 vibrations) 




/ 



tuning-fork is placed on any of the vertebral spines, a trem- 
bling or whizzing sensation is perceived. The skin, as well 
as the bone, participates in the perception of the vibrations. 
Sensation is diminished or lost (bone-anesthesia) in the 
ataxic stage of tabes. Bone -sensibility may be increased in 




incipient tabes and the vibrations of the fork produce a 
burning as well as the whizzing sensation. 

Bone-sensibility is also altered in other nervous affections, 
thus in hysteria, the application of the fork is followed by 
the sudden disappearance of sensibility of the bone and 
skin. 

If the vertebne or corresponding spinal ner\'e-roots are 
67 



n d y I t h 



r a p y 



sensitive, the vibrations of the tuning-fork are more keenly 
appreciated by the patient. 

7. By finding painful centers.'" For this purpose the 
patient's back is bared and a high tension Faradic coil is 
brought into use. Before applying this current the coil 




Fig. It). — ^PosMrior view of the 



should be tested with a four-to-six inch Geissler tube. If 
the coil is capable of illuminating the tube, then it possesses 
the proper amount of penetrative power. For this diagnostic 
work the Kidder Manufacturing Company of New York 
make a special coil. One pole of the battery (it does not 
make any difference which) is attached to the 6x 6 inch 
moist electrode and placed in front over the epigastric plexus. 
The other electrode (2x2 inches), well moistened, is passed 



V 



a I r a t n 



lightly over the spinal column with a current-strength 
suflScient to be agreeably susceptible. This current is passed 
up and down the entire length of the spinal column with 
ordinary pressure eight or ten times and the electrodes re- 
moved when one will note vivid red spots on a white back- 
ground. The latter become more prominent several min- 
utes after the current is removed. Digital pressure upon 
these spots will elicit sensitiveness, whereas no pain will be 
complained of in the intermediate region. 

These spots are pathognomonic of certain ailments and 
the clinician can almost make a diagnosis from the reflex 
centers involved. 

8. Very frequently, if one pole of a Galvanic current 
(with the other electrode at an indifferent point) is passed 
along the spine, no appreciable sensation is felt until a sen- 
sitive area is attained. 

9. It is known that many patients suffer from pains in 
the head and chest when exposed to draughts. The latter 
may be substituted by a current .of cold air from an air- 
pump, which, when directed at the vertebral exits of the 
affected nerves, will reproduce the pains from which the 
patient suffers. Very often the pain is also reproduced when 
the air is directed on the site of the reflected pains. 

Other methods for the elicitation of vertebral tenderness 
are described on page 72. 

Having located by any of the foregoing methods the area 
of tenderness, it is well to employ some mark for future refer- 
ence in treatment. For this purpose a stick of nitrate of 
silver, slightly moistened, may be used as a pencil, thus 
leaving a line which cannot be effaced. If one desires to 
remove the stain of the latter, apply a drop of tincture of 
iodine and then ammonia, or use potassium iodid solution. 



69 




DEDUCTIONS RESPECTING VERTEBRAL PAIN. 

For the objective elicitation of pain, one must exclude 
cutaneous hyperesthesia, which is a dominant factor in the so- 
called hysterical spine and which is present in many neuroses. 
Here, when the skin is lightly touched or pinched without 
any pressure on the bone, pain is experienced. If the 
patient's attention is diverted the identical spot may be 
touched without eliciting any pain. Friction of the tender 
area with a rough fabric of cotton to induce irritation of the 
skin is often followed by disappearance of the painful areas. 

Tenderness of the vertebrse, rather than pain, is rarely 
absent in neurasthenia and sensitive areas may be demon- 
strated in the latter affection as well as in hysteria. 

These topoalgias may not disappear until treatment Is 
directed to the general condition. 

Topoalgia limited to the vertebral column is known as 
rachialgia. In the hysterical spine there is usually a history 
of traumatism and it must be recalled that hysteria long 
latent and unrecognized may be awakened into obvious 
activity by a blow or accident. 

To determine whether a given sensitive area is real or 
simulated, the following signs may be employed : 

1. Mannkopff's sign. — Take the pulse-rate before, dur- 
ing, and after pressure is made on the sensitive area. If the 
pulse becomes increased in frequency it is a proof that the 
pain is genuine. 

2. Sign of Lcewi. — Dilatation of the pupil is in direct 
proportion to the intensity of the pain. Thus, if in a healthy 
man one exercises energetic pressure on the testicle, the pupil 
dilates, whereas in the tabetic in whom the testicle is in- 
sensitive, no pupillary dilatation is observable. 





Vertebral T 



enderness 



3. In neuroses the spine is not rigid at the points of 
sensitiveness. 

In diagnosis one must look for other symptoms suggestive 
of a neurosis. 

In children radiating pains dependent on vertebral disease 
are frequently misinterpreted, as headache, cough or stom- 
achache. 

In Pott's disease reflex muscular spasm is associated with 
pain. In disease of the cervical region the head is held 
stiflay or is supported with the hands. 

In disease of the dorsal region the pain may radiate to 
the chest, respiration may be groaning and night cries occur. 

In lumbar disease the pain is referred to the legs or lower 
abdominal region. In Pott's disease there may be absolutely 
no local pain on pressure, but spasm of the spinal muscles, 
especially on an attempted movement, is practically always 
present and is an early sign. 

Angular deformity of the spine is a late manifestation 
of the disease. 

Pains due to other causes are discussed later. 

VERTEBRAL TENDERNESS. 

The elicitation of the dermatomes of Head is a tedious 
method of examination and not always accompanied by 
satisfactory results for the reason that a great amount of 
experience is necessary. Alsberg*^ in the examination of 200 
women (with gynecological affections) found cutaneous 
areas of hyperalgesia in only seventeen, ten of whom were 
hysterical. Therefore, he could attribute no diagnostic im- 
port to the zones in question beyond commenting on the fact 
that hysterical stigmata must be excluded before the zones 
of hyperalgesia could be regarded as trustworthy. 

There is no longer any doubt concerning the fact that 

71 



spinal tenderness corresponding to different segments of the 
spina! cord is associated with visceral disease. To attain 
definitiveness of localization, however, it is necessary to care- 
fully examine the vertebra? by percussion (page 66), or bv 
palpation; place the patient in the recumbent position, first 
on the right and then on the left side, to secure muscular 
relaxation, for it is quite evident that a contracted muscle 
over a given area of sensitiveness will thwart the elicitation 
of pain. 

If the patient is seated the muscles may be relaxed by 
having the patient lean backward. 

Pressure with the finger (care must be taken that the 
pressure is equal) is next made over each intervertebral 
foramen and, if contracted muscular bundles or pain can be 
demonstrated by the palpating finger, vertebral tenderness 
is present. 

The writer has frequently found that, firm pressure on the 
sensitive vertebrae may evoke pain in lieu of tenderness and 
what is of greater diagnostic import is the fact that, some 
of the sensations from which a patient suflfers may be 
reproduced. 

Many recent writers, notably Arnold'^ and Ludlum", 
found that the areas of vertebral tenderness correspond to the 
vaso-motor centers in the spinal cord and that there exists a 
compensatory relationship between the blood-vessels of the 
cord and those structures supplied by the posterior primary 
divisions of the spinal nerves. 

The vaso-motor nerves are evidently not wholly concerned 
in vertebral tenderness. Physiology teaches that our con- 
scious sensations do not originate in the viscera to which 
the afferent nerves are distributed and where they are stimu- 
lated. On the contrary, the ner\'es merely transmit the 
stimuli to the gray matter of the spinal cord (section of which 
72 



Vertebral Tenderness 

abolishes sensations of pain without affecting the tactile 
sensations), whereby through summation they produce 
changes in the cells of the gray matter. Such changes are 
identified with hyperesthesia and hence the vertebral 
tenderness. 

It is known that frequently repeated painless tactile 
stimuli may eventually arouse the sensation of pain. 

Again, a neuritis at first limited to a visceral nerve may 
pass upwards (ascending neuritis) and involve larger nerve- 
trunks or even the spinal cord. It is in this way only that 
one can explain the vertebral tenderness which persists after 
apparent recovery from a visceral disease. 

In addition to the vaso-motor and sensory reflex phenom- 
ena in visceral disease there are also motor symptoms. The 
latter may be experienced by either an irritation or paresis. 
Thus, in angina pectoris, the constriction around the chest 
is dependent upon a contraction of the intercostal muscles. 
Paretic symptoms may attend a paroxysm and enfeebled 
power of the muscles of the left arm is present. In the inter- 
paroxysmal periods of angina, as well as in other cardiac 
lesions, sensory, motor and vaso-motor symptoms may be 
demonstrated in several segments of the spinal cord, and 
Mackenzie's conception of them is as follows: In cardiac 
disease (as a paradigm) a persistent irritation of the sym- 
pathetic nerve conduces to the irritation of the spinal seg- 
ment at a site where the fibers of the heart connect with the 
spinal cord. Irritation of the sensory part of the spine con- 
duces to the sensation which is projected into the periphery 
innervated by the nerves of the spinal segment (law of 
MuUer). After this manner the motor and vaso-motor 
symptoms are of like segmental character. The following 
table fairly represents the areas of vertebral tenderness in 
visceral disease and corresponds to the distribution of the 
spinal segments. 



S p 



n 



t h 



r a p y 



VERTEBRAL TENDERNESS IN VISCERAL DISEASE. 



VISCERAL DISEASE.* 



Gastric ulcer. 



Cholelithiasis (Gall-stones). 



Cardiac diseases. 



Pulmonary diseases. 



Gastric diseases. 



Pelvic diseases. 



vertebral tenderness. 

At the level of and to the left of 
the loth to the 12th dorsal 
vertebra. 

Somewhat to the right of the 12th 
dorsal vertebra. Painful area 
may persist for weeks after an 
attack. 

Usually to the left of the first four 
dorsal vertebrae. 

From the 3d to the 6th dorsal 
vertebra. 

From the 4th to the loth dorsal 
vertebra. 

At the 4th and 5th lumbar verte- 
brae. 



The foregoing table is based on the observations of 
different writers on the subject and the author presents the 
following table of vertebral tenderness in visceral disease, 
which he has elaborated after palpation of the palpable 
organs and by aid of his visceral reflexes (Fig. 30). Thus, 
in myocarditis, the symptoms of this affection may be elicited 
by concussion of the four lower dorsal vertebrae (Fig. 5), 
which manoeuver provokes dilatation of the heart. If the 
counter-reflex of cardiac contraction is provoked by concus- 
sion of the 7 th cervical vertebra, the area of vertebral tender- 
ness disappears at once. 

One may also note that the vertebral tenderness after 
palpation of an organ is of a few minutes duration only, and 



*Vide also the observations of the Griffin brothers (page 2). 

74 



Vertebral Tenderness 



if present before manipulation of the diseased viscus it is 
accentuated after such manipulation. The point of tender- 
ness is located either at the side of the vertebrae or at a point 
4 cm. from the median line of the spinous processes or m 
both situations. It is better to determine vertebral tender- 
ness before palpating the organs, for otherwise one is unable 



kirr MS 



9IEML 



^f^ATj 



^^rr^na^n 






%%crMt^;^t^6iij^ 




fifsttfs^ 



^rOHTLlMT^ 






Fig. 30. — Vertebral areas of tenderness after palpation of the viscera. The 
localization is only approximate. 

to say whether the tenderness in question was not already 
present. 

A practical point in relation to these areas of vertebral 
tenderness after palpating a sensitive organ, joint or tissue 
is the following fact : If the area of vertebral tenderness is 
thoroughly frozen, the organ, joint or tissue may be manipu- 
lated for a time with either diminished or no pain. Even the 
subjective pain may disappear for hours after the freezing. 

75 



S p 



I 



I h 



^ 
^ 



If the sensibility of the skin over the painful organ, tissue 
or joint is tested with a pin before and after freezing, it will 
be noted after the latter manoeuver that the skin is anesthetic. 
This anesthesia is likewise of variable duration. The cita- 
tion of two observations will make my meaning more lucid 

I. The subject has gout located in the left metatars 
phalangeal articulation of the big toe. The latter is ex-J 
quisitively tender on manipulation. There are no vertebra 
points of tenderness. The toe is now manipulated and when-1 
ever it is moved a localized muscular spasm may be palpated 
at the side of the spine of the nth dorsal vertebra. Within 

a minute two points of vertebral tenderness may be located , 
corresponding to the left side of the nth dorsal vertebra and! 
another about 4 cm. to the left of the spinous process of thea 
latter vertebra. 

The vertebral areas of tenderness are now thoroughly 
frozen and within two minutes the big toe may be manipu-1 
lated without pain. The skin over the toe in question is-l 
anesthetic. The anesthesia lasts only three minutes, but thai 
patient is without pain in the joint until the following day.-j" 
Again the vertebral area (which has been marked with &■ 
stick of silver nitrate to avoid a repetition of localization) isl 
frozen and the patient is without pain for two days. Tw 
more freezings sufficed to control the pain completely. 

II. The subject has an ulcer of the stomach. A sensi- 
tive vertebral point is already present, but when the tender 
point over the stomach is subjected to pressure, the vertebral 
area becomes decidedly more sensitive. The latter area i 
now frozen, after which procedure the sensitive point ovH 
the stomach may be manipulated with scarcely any pain i 
all. The subjective pains of the patient disappeared fori 
only six hours. Freezing was again executed and th 
evanesced for twelve hours. 



Vertebral Tenderness 

Now to the average physician it would be ridiculous to 
assume that freezing over the area of vertebral tenderness was 
anything more than a palliative measure, yet sober thought 
endows analgesia with curative action. 

The use of anesthetics to wounds will hasten their healing 
and by so doing we are executing what the author is pleased 
to call a "peripheral rest-cure." Rest of any kind in the 
treatment of painful organs or tissues is curative. 

The author has seen abraded surfaces on the lips and 
mucous membranes, which having resisted treatment for 
months were regarded as clinically malignant. These 
abraded surfaces were constantly irritated by cauterization 
and the use of antiseptic lotions, yet in a few days a pro- 
tective coating of collodion over the abraded surfaces sufficed 
to cure them. 

One must also remember that the nerves which convey 
sensory impressions also carry trophic fibers. 

Take again coughs. When the sinusoidal current is used 
with one electrode over the sacrum and the other applied 
alternately over the spinous processes, it will be found that a 
reflex cough can be excited in many instances over the 
spinous processes of the 6th, 7th, 8th and gth dorsal vertebrae. 
Patients with persistent coughs will often show areas of 
vertebral tenderness corresponding to the vertebrae in 
question. If now, the tender areas are thoroughly frozen, 
it is an excellent means of inhibiting a cough. Inhibition of 
a cough is, in many instances, a curative measure and when 
we employ narcotics with discretion to subdue a persistent 
cough in bronchitis and other pulmonary aflfections recovery 
is hastened. Concerning the action of freezing for the relief 
of pain, vide page 172. 

The author has also noted that areas of vertebral tenderness 
may be elicited when definite areas of the skin are irritated 

77 



S p 



n 



t h 



r a p y 



by pinching or by means of a point of a pin. Such areas of 
tenderness are likewise of short duration and. appear on the 
same side of the vertebral column (or 4 cm. from the spinous 
processes) corresponding to the side of cutaneous irritation. 
The areas of tenderness may not appear for fully a minute 
after scratching or pinching a definite cutaneous area. 






Ll^0^A 4C&/oV«- - 




^VnhcaF'^>^'^-^^K 






^^ THtGH 



^yjo^A^Tm^^'^ VCCVI.*'^*^'^^ 



Fig. 31. — Approximate areas of vertebral tenderness elicited after irritation 
of cutaneous areas in different regions. 

Localized spasm of the spinal musculature is associated 
with the tenderness, i. e,, each time the skin is irritated the 
finger detects a muscular contraction corresponding to the 
area where tenderness will subsequently appear. By this 
means one is now in the possession of an objective method 
for determining pain-reaction to cutaneous stimulation. The 
intensity of pain is an individual question and depends as 
much on the sensitiveness of the registering apparatus as it 
does on the degree of stimulation. 

78 



Vertebral Percussion 

^^-^-^■'^— ^-^■^— ^^ ^— — — — — — — ^— — ^— — — ^^— 

The localization of vertebral tenderness in the writer's 
experience cannot be governed by any fixed rules, the individ- 
ual case only must serve as a criterion. 

The various therapeutic methods discussed in a sub- 
sequent chapter (chapter V), when applied to the areas of 
tenderness are endowed with considerable value in influencing 
the visceral condition. This statement applies with special 
cogency to the vaso-motor and viscero-motor fibers from a 
given segment. 

Intercostal neuralgia is a frequent condition respon- 
sible for vertebral tenderness and is discussed at length on 
page 1 86. 

VERTEBRAL PERCUSSION. 

The tracheo-bronchial glands are enlarged in pertussis 
and in other infectious diseases, notably in children. 

In every one of 127 cases of tuberculosis, Northrup found 
the glands enlarged. 

Bronchial phthisis has been fully described in the 
literature but the scope of such description has been limited 
in regarding it as an affection peculiar to children with symp- 
toms suggestive of increased intrathoracic pressure. 

The author has portrayed*® a picture of bronchial 
phthisis occurring in adults which in all essentials tallies with 
the tableau of s)anptoms common to pulmonary tuberculosis 
with which it is frequently confounded. In an analysis by 
the author of 100 cases of bronchial phthisis the following 
diagnostic conclusions were formulated : 

1. There is a history of cough which is spasmodic in 
character and almost suggests the brazen, metallic cough 
of aortic aneurism. 

2. Tubercle bacilli may be found in the sputum after 
repeated examinations, and then only when the bronchial 
^nds have suppurated and perforated the bronchus, or 
when tuberculosis is present elsewhere in the lungs. 



3- Dyspnea is out of all proportion to the signs obtained 
by physical examination of the lungs. 

4. Dullness of the lungs anteriorly ajid posteriorly, 
corresponding to the bifurcation of the trachea (at about the 
level of the intervertebral disc between the 4th and 5th dorsal 
vertcbrie). 

5. The Smith and Hare sign, viz., when the patient 
throws the head well back a "purring" sound is heard when 
the stethoscope is placed below the suprasternal notch. 

6. The Rcentgen ray evidence (enlarged glands), viz., 
when the target of the tube is so placed that when the ra)'S 
are traversing the chest, they will fall at a point corresponding 
to either the right or the left side of the vertebral column 
posteriorly corresponding to a point just below the bifurcation 
of the trachea. 

Among the signs cited dullness over the manubrium stemi 
anteriorly and posteriorly corresponding to the 4th, 5th and 
6th dorsal vertebrae is common. 

It mifst be recalled, however, that the region correspond- 
ing to the 5th dorsal vertebra is normaUy dull, the dullness 
extending for a short distance on either side of the vertebral 
column but more to the right than to the left side. The 
shape and size of this square patch of dullness, if much 
modified, may indicate enlargement of the bronchial glands. 

The enlarged bronchial glands often escape detection by 
percussion, owing to vibration of the sternum and spinal 
column. 

Insomuch as the method of vibrosuppression^" is of great 
value in topographic percussion of the chest, brief reference 
will be made to it at this time. 

If one percusses the normal chest, say beneath the 
clavicle, a sound is produced which is the product of the 
vibration of the lung tissue and the thoracic walls. It is 



'■^ibrosuppression 




Fk. 33. — The vibrosuppressor and ils application (o the chtst. 



S p n d y I 



t h 



a p y 



the summation of this \'ihration which interferes ^vith ihi- 
chcitation of the dullness of the airless organs in juxtaposition 
to the lungs. If the vibration in question can be eliminated, 
the definition of the viscera will prove easy of attainment 
Briefly, lung resonance is made up of two chief factors, viz.. 
vibration of the air In the lungs and vibration of the sternum. 
The latter is essentially a sounding-board. Thoracic vibra- 
tion can be eliminated as far as possible by percussion of 
the organs at the end of a forced expiration, when there is 
comparatively little air in the lungs to vibrate, and by sup- 
pressing the \ibrations of the sternum by means of the 
vibrosuppressor (Fig. 32). 

The apparatus is modeled after a tourniquet, consisting 
of a pclote, screw, band (6 cm. wide) and clamp for fixing 
the latter. It is so applied that the pelote rests on the 
xiphoid cartilage of the sternum. The pelote is made to 
compress the cartilage by aid of the screw with all the pressure 
the patient can tolerate. Percussion is then executed during 
the time the apparatus is employed and preferably during 
suspended respiration after forced expiration. In the 
absence of the apparatus, firm pressure made on the lower 
end of the sternum by the hand of an assistant will aid topo- 
graphic percussion during the time the patient has suspended 
respiration after forced expiration. More recently, the 
author has noted that suppression of the vibrations of the 
spinal column by aid of compression of the latter by the hand 
of an assistant is of material aid in percussing enlarged 
bronchial glands and defining the lower border of the liver, 
spleen and stomach. In many instances it is better to com- 
press the sternum and spine simultaneously. 

Among other signs of enlarged glands are those of 
Grancher (unilateral restriction of breathing) and Petruschky 
(area of tenderness between the shoulder blades). 




B a 



a 



CHAPTER IV. 

SUMMARY OF SPINAL DISEASES AND SYMPTOMS. 

BACKACHE — CHEST DEFORMITIES— COCCYGODYNIA — ^FAULTY ATTITUDES 
— LITIGATION BACKS — LUMBAGO — NEUROTIC SPINE — OSTEO-ARTH- 
RITIS — ^pott's disease OF THE SPINE — SACRO-ILIAC DISEASE — 
SACRO-ILIAC RELAXATION — SPINAL CURVATURES — SCOLIOSIS — 
KYPHOSIS AND LORDOSIS — ^ANGULAR CURVATURE — SPONDYLITIS — 
SPONDYLOLISTHESIS — ^TRAUMATISM OF THE SPINE — TUMORS OF 
THE SPINE — ^TYPHOID SPINE — VERTEBRAL INSUFFICIENCY — DIAG- 
NOSIS OF SPINAL DISEASES — ^PAINS — ^DEFORMITY — COMPRESSION 
OF THE SPINAL CORD — ^PARAPLEGIA — ^TUBERCULOSIS — SYPHILIS — 
GONORRHOEA — RHEUMATISM — RICKETS — SPINAL MENINGITIS. 

BACKACHE. 

^T^HE popular conception of the etiology of backache in 
-*- men is the kidney, and in women pelvic disease. 

As a matter of fact the kidney and pelvis are infrequently 
concerned in the etiology of this common aflfection. 

It is practically axiomatic that organic heart-lesions as 
a rule are dissociated with pain and the same may be said 
of the average renal disease. 

I adopt the following simple manceuver for excluding 
the kidneys as factors in the causation of backache : Place 
the pleximeter first over one and then over the other kidney 
in the lumbar region and practice forcible concussion. The 
hands (Fig. 3) may be employed for a similar purpose. 

By aid of this transmitted palpation of the kidneys no 
pain can be elicited in the norm, but if the pain from which 
the patient suffers is of renal origin the exact nature of it may 
be reproduced by this manceuver. This method of trans- 
mitted palpation is equally efficient in determining the sen* 
sitiveness of the liver. 

83 



The lumbar muscles {lumbago) are commonly concerned 
in the etiology of backache and they must be excluded in 
diagnosis (page 99). 

When the muscles in question are involved, bending far 
forward suddenly will stretch the muscles and elicit pain. 
Backache dependent on pelvic or renal disease would 
uninfluenced by such a movement- 
It must be remarked, however, that the latter movemenj 
and pain in lumbago are influenced by the muscles involved. 
Thus, involvmcnt of the erectors permits bending forward, 
but elicits pain when the vertebral column is straightened; 
when thejlexors (quadratus and psoas) are involved, bending 
forward is painful and rotation of the thigh (psoas) causes 
distress; when the serratus posticus is involved, deep breath' 
ing and not spinal movements causes pain. 

Backache may be located in the lumbar, lumbo-thoracii 
sacral or coccygeal regions. 

In women, the neurodc spine, sacro-iliac disease, con- 
stipation, hemorrhoids and pelvic disease are frequent causes'' 
of backache. If constipation is present in either sex the 
pain is located in the regions of the ascending and descending 
colon and is associated with tympanites. The expulsion of 
gas brings temporary relief and the same may be 
of carminatives, purgatives, enemata and a diet (non- 
amylaceous) which inhibits the formation of gastro-intestinal 



1 

rd, 
td; 
ng 
5es 

th- 

cic^ 

sn-^^H 

ises^H 

the 

ing 
,.iof 
sai4^H 
non-^H 

final ^^ 



^ 



In GASTRIC TYMPANITES, backache may be felt in the 
left interscapular region. The writer has shown*' howj 
easily the heart may be dislocated by distension of the 5tom<fl 
ach. It is unnecessary to descant on the practical value of" 
this observation. Heart -dislocation from stomach-dilatation 
is associated with a circumscribed area of dullness in the 
left interscapular region. Over this area, bronchial respira-J 



B 



tion is heard. When the patient leans far forward, dullness 
and bronchial breathing disappear to reappear when the 
erect attitude is resumed (Fig. 34). 

The foregoing syndrome may be reproduced synthetically 
by artificial distension of the stomach. An enormously dis- 
tended heart may produce identical signs. 

Artificial insufflation of the colon is incapable of producing 
the same degree of cardiac luxation. In gastro-intestinal 
affections, notably ulcerative in character, pain in the back 





L 



Fic. 33. — Radioscopic appearance of the heart before and after the admin- 
btration td a Seidlits powder. The silhouette of the heart is represented by the 

often ensues within a few minutes after the ingestion of fluids 
and food. 

I have employed the phrase eespiratory ataxia, to 
designate many respiratory neuroses which, in my experience, 
are associated with a defective tj-pe of breathing and with 
inco-ordination of the muscles of respiration. In males, 
the type is costal instead of abdominal, and in women, 
abdominal instead of costal. These patients have one 
symptom in common: A paroxysmal tendency to "catch 
the breath." There are, however, other symptoms, notably 
backache, syncope, dyspnea, cardiac palpitation and insomnia. 
85 



Merc inspection makes the diagnosis, viz., the recognition 
of the reversed type of breathing. Auscultation elicits no 
respiratory murmur in the lower lobes of the lunf^ in males 
and the upper lobes in females. Encircling the chest with 
a rubber bandage to e.xclude costal breathing and the abdo- 
men in females to exclude abdominal respiration brings 
immediate relief, whereas re-education of the type of respira- 
tion results in cure. 




Fig. ^n-^Patch of flullness and area of branthial rcspiralion in dislocation 
of the heart upward after artificial distension of ihc aloniach. The adjoining 
illustration shows an increase in the area of dullness when the same palieni is 
leiLning batknard. 

A nasal anomaly may be the exciting factor and this may 
be demonstrated by the immediate relief of the symptoms 
following cocainization of the nasal mucosa. 

Hemorhhoids may induce reflex pains running to the 
back but more often down the left leg, thus simulating 
sciatica. As a rule such hemorrhoids have abraded surfaces 
and for this reason, an ointment containing alarge percentage 
of orlhoform is effective as a local anesthetic and, in this 
action a diagnosis may be made. 

If, for instance, the pains in the back are ameliorated 





Backache 

^^-^-^■'^— ^-^■^— ^^ ^— — — — — — — ^— — ^— — — ^^— 

after the application of the salve to the hemorrhoid, we know 
that the latter is concerned in the etiology of the pains. 
More radical measures addressed to the cure of the hemorr- 
hoids are equally eflScient and the author can highly recom- 
mend the daily application of Monsel's solution to the hem- 
orrhoids by means of a brush once or twice daily. 

Other rectal affections, notably fissures y may be excluded 
by the local application of a 5 or 10 per cent solution of 
cocain. 

One must also think of the post-operative -backache 
provoked by the straight dorsal position of the patient during 
a protracted operation. This may be prevented by flexing 
the limbs and body and using cushions under the shoulders, 
knees and small of the back during an operation. 

Rose^* directs attention to a chronic periostitis of one 
of the spinal processes (lumbar and sacral usually) as an 
important cause of backache. The latter may be detected 
by the pain produced by pressure with the finger on the 
implicated spine. Immediate relief is secured by one appli- 
cation of leeches to the spinal process and cure, by the daily 
application of iodine-tincture and potassium -iodid internally. 
When over-distended seminal vesicles cause backache, 
immediate relief is often achieved by stripping the vesicles. 

Prostatic disease may cause backache which is often 
misinterpreted as sciatica or lumbago. This is due to the 
intimate association existing between the pudic nerve from 
which the prostate receives its spinal fibers and the roots 
of the lumbar and sacral plexuses. 

A PENDULOUS ABDOMEN may cause backache and this 
may be demonstrated by the relief secured by raising the 
abdominal walls with both hands. If the latter manceuver 
is effective, a proper abdominal support must be worn. 
Here the pain is probably caused by traction of the mesentery 

87 



S p 



d V / 



/ h 



r a p y 



on the spine. The drag of the abdomen in obese subjects 
will cause lordosis and strain on the sacro-iliac articulations. 

In chronic appendicitis backache may be present and 
is increased in severity after fatigue. Byron Robinson has 
shown that the appendix is frequently in contact with the 
psoas muscle and may, therefore, be bruised by the action 
of this muscle. With the patient in the recumbent posture 
sudden extension and flexion of the thigh on the trunk will 
often elicit severe pain. On the other hand, the pain is 
relieved when both thighs and knees are partly flexed in 
recumbency. 

Aneurism of the thoracic aorta is characterised by sharp 
paroxysmal and lancinating pains. Anginal attacks are not 
infrequent when the aneurism is located at the root of the 
aorta. The pains often radiate down the left arm, up the 
neck or along the upper intercostal nerves. In aneurism 
involving the descending aorta, one of the most frequent 
symptoms is pain and Huchard, referring to this form of 
aneurismal neuralgia, says that when one is dealing with 
persistent pain of long duration which cannot be explained, 
which resists ordinary medication and which is either in- 
creased or diminished in severity in certain attitudes of the 
patient, one should always consider aneurism as a probable 
diagnosis and, if no tumor can be demonstrated, one must 
have recourse to the x-rays for additional evidence in 
diagnosis. 

If backache is caused by pelvic disease, palpation of 
the ovaries and movements of the uterus should reproduce 
the pains from which the patient suffers. The pain from 
uterine affections is often located in the upper sacrum and is . 
described generally as a dragging sensation. In sucllS 
instances retro-flexion is the most common cause. 

Referring to the pains of pelvic inflammations, Kellyl 




B a 



a 



makes the following pertinent observation: Inflammatory 
pain has a definite habitat. . . . The pain of inflanmia- 
tion is a fixed point ; it is never in one place to-day and then 
at some remote part of the body to-morrow, one day in the 
shoulder and the next in the foot or calf of the opposite leg. 
. . . . It is a safe working hypothesis to conclude that 
a patient who complains of a definite pain and who from 
day to day and week to week is definite in her complaint as 
to the character and seat of the pain, has some gross lesion. 
Garrigues*' divides pelvic backaches into two varieties : 

1. When pain and tenderness are located at the 4th and 

5th lumbar vertebrae (spinal-center for the internal 
pelvic organs) ; 

2. When a tender spot can be located on either side of 

the 2nd sacral vertebra. 

The latter variety is caused by a cellulitis of the utero- 
sacral ligaments. 

Garrigues contends that in the norm the utero-sacral 
ligaments are so elastic that the uterus can be brought for- 
ward bimanually until arrested by the pubic bones. When 
the ligaments are inflamed, any movement of the uterus 
forward causes acute pain in the back. 

Many persistent backaches in women owe their origin 
to improper methods of dress. Here an important element 
is the pressure of corsets. 

In the developmental period of some of the acute 
INFECTIONS, notably small-pox, dengue and influenza, back- 
ache is a frequent concomitant, the pathology of which is 
obscure. 

Associated with what is known as indurative head- 
ache (which, according to Edinger, is regarded as the most 
frequent form of headache) there are also pains in the neck 

89 



d 



I 



t h 



and back caused by indurations within the bodies of the 
muscles due to a chronic myositis. 

The indurations are painful on palpation and may feel 
like grains of shot. They are most frequently located in the 
muscles of the head and neck, although other sites are nol 
exempt (Fig. 35). 




Fio. J5.— The 
Yawger). 

Several months may be necessary to effect a cure and 
this may be attained by removal of the indurations by means 
of vibration and Galvano -therapy but most effectually by- 
massage. 

This subject is more exhaustively discussed elsewhere-T 
One must remark, however, that fibrous indurations a 
90 




B a c k a c h e 

• 

not essentially rheumatic insomuch as they may also follow 
infections and local injuries or strain of the muscles. In my 
experience, the indurations are best detected by relaxing the 
aflfected muscle and then rubbing the skin with vaselin when 
firm pressure with the finger will demonstrate the nodules. 
After a few stances of massage the indurations will become 
more defined. 

Depage, of Brussels, directs attention to the infrequency 
of backache (in lo to 15 per cent of the cases) m floating 
kidney (nephroptosis) and observes that, notwithstanding 
nephrorrhaphy, the pains in the back continue. Here, as in 
backache referred to other causes, the following condition 
has been overlooked by clinicians, viz., owing to deformity 
of the ribs, the loth or nth rib comes in contact with the 
crest of the ilium either on one side or the other and the 
rubbing thus provoked gives rise to a dull, intermittent pain 
which is accentuated by movements. The false position of 
the ribs may occur as a result of scoliosis. The loth and 
nth ribs are painful on palpation and there is little or no 
space between the lower ribs and the crista ilei. Resection 
of the anterior ends of the ribs in question resulted in cure 
when mechanotherapeutic methods failed. 



55 



SYNOPTIC TABLE OF BACKACHES.* 
DISEASES OF THE SPINAL CORD. 
LOCATION OF PAIN. CONCOMITANT SYMPTOMS. 

In distal parts of the body de- No spinal rigidity nor vertebral ten- 
pendent on the pain-fibers that derness. Dependent on the seg- 
are irritated. ment of the cord involved, motor 

and sensory disturbances are 
present with loss of reflexes. 

♦The essential facts of this table have been gleaned from a paper by Dr. C. M. 
Cooper of San Francisco, which was kindly placed at the disposal of the author 
prior to its publication. 

91 



1 S p ?i d y I 


otherapy 


DISEASES or THE SPINAL-ROOTS AND MEMBRANES, 


May occur either in juxtaposition 


Pains occur in definite anatomic 


to the lesion or in distal parts 


zones and are inclined to encircle 


and is intense and shooting in 


half the trunk or shoot into the 


character. 


extremities. Spinal rigidity and 


tenderness are usually absent, 


r 


thus excluding vertebral disease. 


^^^1 


If a single nerve-root is involved 


^^^f 


it may be the precursory symp- 


^^^P 


tom of herpes. 


1 DISEASES OF THE 


'EHTEBRAL COLUMN. 


Pains are root-like in character 


Deformity may or may not be 


with or without vertebral ten- 


present. Usually spinal rigidity 


derness. 


and impaired mobility corre- 




sponding to the vertebrae impli- 




cated. The nature of the spon- 




dylitis (5. V.) must be determined. 


EXTRA-VERTEBRAL ARTtCDLAR DISEASES. 


Pains may be confined to the 


Backache is worse in the recumbent 


region of the ribs, scapula: or 


posture and referred pains in- 


ilia. In abnormal sacro-iliac 


nervated by the lumbo-sacral 


mobility iyiie sacro-iliac dis- 


cord are frequent. ^^^ 


ease), pain is referred to the 


^^1 


sacro-iliac joints or sacrum. 


■ 


DISEASES OF THE MUSCLES AND LIGAMENTS OF THE BACK. ^^| 


Usually described under the gen- 


Rigidity of the back-muscles maf^^H 


eric term lumbago. Pains are 


be present but no pain can b^^^H 


increased by movements which 


elicited by percussion of thc^^H 


contract the muscles. Muscles 


vertebrae and there are no nervM^^^I 


tender when compressed by 


root pains. ^^H 


the fingers. The Faradic cur- 


^1 


rent is useful in diagnosis 


^1 


1 (page 99). 


^H 


BACKACHES FROM STATIC ERRORS. .^^H 


In taking the strain off of distal 


The diagnosis is established when 


anomalies, the muscular fa- 


the flat-foot or knock-knee is 


t tigue graduates into pains. 


remedied by some orthopedic ^^^ 


I" Rotary or lateral curvature 


manceuver. ^^H 


1 may be present. 


^^B 



B 



a 



a 



BACKACHES FROM VISCERAL DISEASE. 



2. 



The visceral stimuli may be: 
I. Spasm in a hollow muscular 
organ (ureteral colic); 
Distension of a capsule (en- 
larged spleen, liver or kid- 
ney) 

Inflamed serous coverings 
(adherent appendix) ; 
InsuflScient blood supply (ab- 
dominal arteriosclerosis) ; 
Excessive functioning (exces- 
sive venery) ; 

Pressure (tumors and aneur- 
isms) ; 
Visceral pains are dissociated with 
excessive vertebral tenderness or 
stififness or by movements which 
call the fasciae and ligaments into 
play as in lumbago. 



6. 



Usually referred pains, which are 
sharp, aching or stabbing. 
Hyperesthesia over zones cor- 
resp)onding to the areas inner- 
vated by the disturbed spinal- 
segments (Figs. 23, 24, 25 and 
26) and tenderness and rigidity 
of the muscles innervated by 
the same segment. Location of 
pain suggests organ involved: 
I, between the shoulders, 
gastric pains \ 2, right shoulder 
blade or tip, hepatic disease; 
3, left shoulder blade, over- 
loaded heart) 4, dorso-lumbar 
region, varicocele, loaded colon, 
ovarian or testicular disease; 5, 
angle between lowest rib and 
erector spinas muscle, kidney- 
stone; 6, loin, kidney disease; 7, 
base of sacrum, prostatic or 
uterine disease; 8, sacro-iliac 
synchondrosis, distended sem- 
inal vesicles, inflamed utero- 
sacral ligament, pelvic and 
rectal diseases. 



SPECIAL BACKACHES. 

1. Post -OPERATIVE backache. — After operations in 
the supine posture due to improper support of lumbar arch 
with muscular relaxation during anesthesia. The backache 
in women occurring at night is due to improper support of 
the lumbar arch and may be prevented by a pillow under 
the loins during sleep. 

2. Professional backache. — Observed in dentists 
and surgeons who assume a constrained posture and the 

93 



S p 



t h 



r a p y 



remedy consists in raising the right leg and placing the right 
foot on a stool ; thus the lumbar spine is partly unarched and 
strain is removed from the stretched ligaments. 

3. Hysterical backache, — vide hysterical spine. 

4. CoccYGODVNiA (page 95). 

CHEST -DEFORMITIES. 

The configuration of the thorax is frequently modified as 
a sequence of curvature of the spine and the deformities 
are as follows : kyphotic, scoliotic and scolio-kyphotic. 
Such deformities are readily recognized by the short thorax, 
low stature and the exaggerated breadth of the shoulders. 

The RACHITIC chest is especially characterized by the 
keel -shaped prominence of the sternum (pigeon -breast) 
and may be associated with deformities of the spine, notably 
scoliosis and kyphosis. The boat-shaped chest [ih^wax en 
batteau) has only been obser\-ed in syringomyelia and 
consists of a depression in the median line of the upper 
portion of the anterior chest-wall. 

In the ALAR or pterygoid chest there are prominent 
scapulae. 

Projection of one scapula indicates the presence of a. 
lateral curvature. 

In 1743, Hunauld described the condition known as 
CERVICAL BIB. The anterior limb of the transverse process 
of the 7th cervical vertebra has an independent center of 
ossification and may develop into a separate bone (known 
as a cervical rib), which may not extend beyond the trans- 
verse process or may form a complete rib attached ante- 
riorly to the sternum. A cervical rib may be present either 
on one or both sides. Since the employment of x-rays in 
diagnosis, the cervical rib is more frequently recognized and 
is not an uncommon condition in explaining many vascular 



I 



c c y g a y n t a 

and nervous symptoms referable to the upper extremity and 
neck. A supposititious osseous growth of the neck may be a 
cervical rib or exostosis emanating from it. 

A cervical rib may exist with or without symptoms. In 
the former event, the symptoms are associated with pressure 
on the subclavian artery (aneurism, gangrene of the hand 
and minor vascular affections ) and on the brachial plexus 
(neuritis). The symptoms may develop suddenly in chil- 
dren and adults. 

COCCYGODYNIA. 

This is a neuralgia of the coccygeal plexus and is also 
known as coccydynia. The chief sign of this aflFection is 
pain in and around the coccyx which is accentuated in the 
sitting posture (sitting-pain), by rising, walking, urination, 
defecation, coitus and during pregnancy. Pressure on the 
coccyx is painful. The pain may be intermittent or con- 
tinuous and dull or neuralgic. With the patient in the dorsal 
or the left lateral position by grasping the coccyx between 
the index finger (in the rectum) and thumb and moving the 
coccyx, the pain from which the patient suflFers may be re- 
produced and in this sense such an examinatipn is diagnostic. 

The affection is chiefly confined to women and is occa- 
sionally observed in children. In quack literature the 
aflFection is often described as the "elongated spinal column." 

Occurring rarely in males, it owes its origin to some 
sexual anomaly. 

The etiology is obscure, the predominant factors being 
traumatism (horse-back riding), pregnancy, labor, rheu- 
matism and pelvic diseases. 

Many writers regard the affection as a neurosis or 
neuralgia and the success attending Graefe's method of 
treatment would suggest the latter hypothesis as correct in 
the majority of cases. Graefe cured all his cases within 

95 



twelve seances by applying one pole of the Faradic current 
to the sacrum and the other pole lo the coccyx and surround- 
ing tissues. 



FAULTY ATTITUDES. 

Above the age of twelve years the normal attitude may 
be roughly estimated by aid of the plumb-line held against 
the back of the sacrum; this line approximates the con- 
vexity of the dorsal spine. 

The FLAT BACK is observed in children with a tendency 
to scoliosis and the hollow back (lordosis), unless due to 
disease, is usually an anomaly of conformation. Round 
SHOULDERS are associated with the following attitude : head 
is flexed and carried fonvard, the shoulders are drooping, 
the chest is narrow and flat, the scapulae arc prominent and 
the physiologic curve in the dorsal region is accentuated. 
The age of puberty is the usual time for the occurrence of 
round shoulders. The etiology is identified with general 
muscular weakness (especially of the posterior shoulder- 
muscles), defective hygiene, supporting the clothing from 
the shoulders in lieu of the waist, and protracted spinal 
flexion from incorrect school furniture which lends no sup- 
port to the back, ■ 

In PARALYSIS AGiTANs the attitude is characteristic t:l 
head and body are bent forward with trunk flexed on thighs 
and fore-arms on the arms. The other essential points in 
diagnosis are : tremor at rest ceasing upon voluntary move- 
ments, mask-like face, monotonous voice and rigidity of 
the back. 

In CERVICAL CARIES the head is held to one side, supported 
by one or both hands in a fixed position. In pseudo- 
HVPEKTROPHIC MUSCULAR PARALYSIS, the enlarged though 
feeble muscles, and the attitude (legs far apart, shoulders 





Litigation Backs 

thrown back, abdominal protrusion and lordosis) are 
characteristic. 

In SHOULDER MALPOSITIONS, with drooping of the 
shoulder forward, rotation of the scapula lowers the glenoid 
cavity, thus causing the humerus to rest against the ribs and 
by so doing, the axillary structures are compressed, resulting 
in circulatory disturbances in the hand and pains in the 
distribution of the brachial plexus. 

LITIGATION BACKS. 

As a result of accident, many individuals suffer from 
symptoms referred to the back which in reality do not exist 
and which often evanesce after a favorable verdict by a jury. 

It is easier for a patient to simulate a disease which 
gives little objective evidence, hence the nervous system is 
a prolific field for the malingerer. 

Simulation of organic nervous disease is extremely diffi- 
cult, and for this reason, the symptomatic picture is essentially 
neurasthenic. Simulation can only be excluded by the 
physician after a thorough objective examination of the 
nervous system. The behavior of the patient, when his 
attention is diverted from his symptoms, must be carefully 
noted. Disease of the cord and membranes may be excluded 
if the reflexes are intact and if there is no distal spasm, 
paralysis or anomaly of sensation. 

Vertebral implication is excluded if there is no vertebral 
tenderness, deformity or limitation of spinal movement. 

If unilateral spasm is present it cannot be feigned. 

In real paralysis, any change in the condition of the 
muscles cannot be feigned. In simulated paralysis, move- 
ment of the involved limb may show some muscular stiffness 
if it is suddenly raised or dropped, or, if motion is secured by 

97 



painful stimuli such as the prick of a pin or a powerful 
Faradic current. 

Under anesthesia the patient may execute movements of 
a simulated paralyzed extremity and in one case of malinger- 
ing, the author induced the malingerer to move his limb 
during hypnosis. 

Anesthesia is easier of simulation than the preceding 
symptom, for the reason that sensibility varies even in the 
norm. Thus women are more tolerant to pain than men 
and even in healthy criminals analgesia is frequently ob- 
served, Polish Jews are said to show anomalies in the per- 
ception of pain. Bailey" asserts, that there are many in- 
dividuals who can suppress any evidence of pain as long as 
their attendon is fixed upon this object. 

The "human pin cushions" in museums really suffer 
pain, but in consideration of the salary they receive, willingly 
submit to the thrusts of the pin. 

In making a sensory examination, the eyes must be blind- 
folded and the tests must be executed without any fixep 
system. Thus, when one leg is being examined, prick the 
anesthetic leg quickly or employ a Faradic current and 
suddenly use the full force of the battery. Again, mark with 
a pencil on the skin the areas of anesthesia and examine 
later to observe if the areas correspond. 

Feigned anesthesia is not limited to the exact distribution 
of the peripheral nerves, nor to the sensory distribution o£ 
the spinal -segments. 

To determine objectively the existence of pain, the signs 
noted on page 70 may be employed. 

The REFLEXES are not under control of the will, hence, 
if modified or lost, feigning may be excluded. It is true, 
however, that the knee-jerk may be inhibited if the patient 
firmly contracts the knee-muscles. 





L u m b a g 



LUMBAGO. 

A muscular rheumatism (myalgia) limited to the muscles 
of the loins and their tendinous attachments is known as 
lumbago. 

An attack of lumbago may occur suddenly after stooping, 
or a sudden twist, hence the phrase, "kink in the back" or 
^^Hexenschuss^' (witches' shot), as the Germans call it. 

The diflFerentiation of pain located in the muscles or 
vertebral ligaments is often diflficult Of attainment, yet, one 
may say, that if the pain is worse in straightening up, the 
erector spinae muscles are involved, whereas implication of 
the ligaments is probably present when the greatest pain is 
experienced when the patient bends far forward. 

Schreiber notes than an intense dull pain extending from 
the sacrum to the 3rd dorsal vertebra dissociated with any 
limitations in the movements of the spine, indicates the 
involvement of the fascia lumbo-dorsalis. Difficult bending 
forward suggests implication of the flexor muscles (psoas 
and quadratus). Involvement of the psoas is indicated by 
the pain evoked in rolling the thigh outward. Pain in the 
region of the 4th and 7th ribs uninfluenced by bending the 
spine but accentuated by breathing, suggests involvement 
of the serratus posticus. 

In general, muscular pain is diagnosed when the muscles 
are tender on pressure and passive stretching or active con- 
traction accentuates the pain. 

When the muscles cannot be grasped between the fingers, 
muscular contraction may be provoked by the Faradic 
current and after this manner, the areas of sensitiveness may 
be elicited. This current is therefore equally efficient in 
diflFerentiating myalgia from pains of other origin. 

Myalgia, in contradistinction to neuralgia, shows no 

99 




periods of cxaccrbation^ but becomes accentuated from 
pressure and active and passive movements and the muscles 
may show changes in volume and consistency. From 
vertebral disease, the diagnosis is usually not difficult (I'idc 
backache). It must be emphasized, however, that per- 
sistent lumbago mav be a symptom of masked Pott's disease. 

Lumbago caused by fatigue is ameliorated by massage, 
which removes the fatigue -toxins. 

Myalgia may also be provoked by an intramuscular 
neuritis or by pressure on the intramuscular nerves by the 
indurated connective tissue of the muscles (page 89). 

Myalgia of rheumatic origin yields to the salicylates 
and when associated with a toxemia dependent upon some 
digestive anomaly, small doses of calomel followed by a 
saline is an effective measure. 

Strapping would be equally efficient in pain of muscular 
or vertebral origin, whereas acupuncture (page 146), if 
efficient, is practically diagnostic of a myalgia. 

By means of strips of adhesive plaster (preferably zinc 
oxid) properly applied to the lumbar muscles without in- 
cluding the spine, immediate relief is often obtained in 
myogenic pain. Almost miraculous in action is freezing 
(page 172) of the skin overlying the affected muscles. Unless 
relief is immediate after the use of freezing no results can 
be expected from its repetition. 

Myalgia of gouty origin demands the employment of 
remedies addressed to the gouty state. 

In URIC ACID LUMBAGO dependent on a supposed pre- 
cipitation of uric acid in the muscles of the back the local 
application of oil of wintergreen (by massage) is, accord- 
to Haig, both diagnostic and curative. For purposes of 
massage I employ an electric massage-apparatus, which is 
illustrated in Fig. 36. 

100 




£■ 



The author does not seriously consider the so-called 
uric-acid theorj'of disease, yet he feels that in a book of this 
character, he dare not obtrude his personal opinion nor 




demoh'sh a theory which has won favor. Therefore, a few 
words are pertinent respecting this theory. Many causes 
have been assigned for the uric-acid diatliesis, but in reality 



L S P n d y I 


Q t h e r a p ^^ 


\ the essential cause may be 


bus summarized : excessive 1 


^ eating and drinking with deficient muscular exercise- 


There is practically no known remedy for eliminating 


uric-acid from the blood and one is constrained to have 


recourse to a diet with the object of diminishing the ingestion 


of foods containing uric acid. 


Adams suggests the following 


diet-lists in cases of uric-acic 


intoxication. ^^^1 


MAY BE 


^ 


While Meat of Chicken, Sparingly. 


Raw Cabbage, "Slaw." i 


Fat Bacon or Fat Pork or Ham. 


Corn on the Cob or from the Tins. 


Macaroni, Spaghetti, Vermicelli. 


Cucumbers, Lettuce, Parsley. 


Barley, and all Cereals and 


Dandelion, Beel and other 


"Flaked" Breakfast Foods. 


"Greens." 


Potatoes in all forms but Fried. 


Beets, Turnips, Squash, Pump- 


Sweet Potatoes. 


,M 


Kale and Spinach, Sparingly. 


Puddings of Crackers, Bread, el^^H 


Flounders, Fresh Cod, Hake or 


without eggs. ^^^ 


Haddock. 


Rice, Sago, Tapioca. 


Fresh Fish, Soup or Chowder. 


Milk, Buttermilk, "Cereal 


Vegetable Soups, with Barley. 


Coffees." 


Game, once a week, Sparingly. 


Chestnuts, Almonds, Walnuts, 


■Cheeses of aU kinds. Very useful. 


Pecans, Grapes, Raisins, Figs, 


Stale Bread, Crackers, etc. 


Apple Sauce, Pears, Lemons. 


Rusks, Cake without Eggs. 


Grape Fruit, Oranges. 




Dried Fruits in Sauces, Sweetened 


TO BE AV 


only when cold and ready to eat. 


OIDED 


Eggs, and foods containing them. 


Pickled, Salted or Preserved Fish. 


Beef. 


Salmon, Bluefish, Mackerel or any 


Veal. 


Oily Fish. 


Pork. 


Mushrooms. ^^ 


Mutton. 


Celery, Kale. ^H 


Lamb. 


Tomatoes, Rhubarb. ^H 


1 Beef Tea. 


New Bread or Biscuit. ^^1 


All Soups made with Meats. 


Made Dishes, as Puddings with 


1 1 ° ^ 



Neurotic Spine 

Potted or Preserved Meats. Eggs. 

Lobsters, Crabs, Clams, Oysters. Hot Griddles, Waffles, etc. 

Dark Meat of Chicken or Fowl. Beer, Wine, Whiskey and all 

Liver, Sweetbreads, KLidneys, etc. Alcoholics. 

Beans, Peas or Lentils, Dried, in Tea, Coffee, Cocoa andChocolate. 

Soups or Baked. Peanuts. 

Bananas, Gooseberries. 

Traumatic lumbago often follows injuries of the verte- 
bral column and is dependent on strain or laceration of the 
tissues which protect the spinal cord. Injury of the spinal 
cord is excluded by the absence of paralysis, anesthesia and 
loss of sphincter-power. In this form of lumbago there is 
pain in the back, aggravated by motion. Painful areas may 
be detected over the vertebral spines and muscles, and 
the latter are usually in a condition of spasm. 

Vide osteo-arthritis (page 105) which is often falsely 
designated as lumbago. 

NEUROTIC SPINE. 

In hysteria and neurasthenia, spinal symptoms may pre- 
dominate conducing to a condition known as spinal irritation 
or spinal neurasthenia. Among the symptoms are : weak- 
ness and pain in the back and intercostal -like neuralgic 
pains, which shoot down the legs. 

The rachialgia may only appear after exhaustion or 
movements of the spine or it may occur spontaneously. In 
practically all cases areas of tenderness may be elicited on 
the spine. 

The diagnosis of the neurotic spine is based on the 
diagnosis of neurasthenia and hysteria. 

In neurasthenia, the chief symptom is tire, without which 
sign the disease cannot be said to exist. 

Amyosthenic symptoms are present (page 52), and it is 

103 



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t h 



rap' 



oidenl, that if tbe hack-musdes (wlndi aie tlie oohr agents 
in maintaining the spine erect) are m iolred in tbe hypo- 
tonicity, backacbes most be of &Eqiieiit mxiuieuce. 

Respectii^ tbe diagnoeis of fayslena, <iDe searches for 
tbe stjgmau (anesthesia, hyperesthesia, etc). 

AcconHng to tbe modeni amceptkni of hysteria. &e so- 
called stigmata are of artificial prodaction, evoked fay tbe 
suggestion of the phnician duriog his examinatioa; beooe 
the stigmata are characterized by mobility, TariabQihr and 
incertitude.* 

If anesthesia b present it may be revealed by certain 
mancBUvers. In the method known as tbaxsfebexce, if a 
coin or any metal is placed on an anesthetic area, the 
latter will show a return of sensibility, whereas another area 
with normal sensilwUty may become anesthetic. The 
manceiivcr may be re\-ersed b\' placing the coin over an area 
of normal sensibility; this in turn becomes anesthetic and 
sensibility is restored in another anesthetic area. 

Janet suggests an ingenious manoeuver. The patient, 
let us assume, has an anesthetic area on the hack. He is 
told to say "yes" each time he feels the prick of the pin and 
' when it is not fell. The examination must be con- 
ducted rhythmically so as to give the patient no previous 
ning. If the patient sa)'s "no" when the anesthetic area 
bed, the nature of the anesthesia is revealed insomuch 
S patient could not say "no" if tactile sensation were 
•ai. In hysteria, the psychic origin of the disturbed 
t is further revealed by the fact that they bear no 
1 to the distribution of the sensory nerves nor to the 
into of the spinal cord. 
"he neurotic spine is frequently associated with diseases 



O s t e -Arthritis 

of the pelvis insomuch as areas of hyperesthesia are fre- 
quently located over the ovaries (ovarian tenderness). 

In the majority of instances the ovaries are not implicated 
and, if bimanual examination of the pelvis is made and the 
finger in the vagina is made to approximate the finger on the 
area of tenderness, it can easily be demonstrated that the 
pain is located in the abdominal walls and not in the pelvic 
organs. 

OSTEO-ARTHRITIS. 

Synon3niis. — Rheumatoid Arthritis ; Arthritis Deformans ; 
Chronic Rheumatic Arthritis ; Rheumatic Gout. 

In this affection pronounced structural changes in the 
joints and cartilages are present. When the spine is in- 
volved, there is hypertrophy and overgrowth of bone. 

The x-rays have been a valuable aid in the recognition 
of these changes which, when present, exclude rheumatism, 
insomuch as the latter affection is unattended by pathologic 
alterations in the cartilage and bone. 

The affection usually occurs between the ages of thirty 
and fifty years and women (notably those who have pelvic 
disease or are sterile) are as frequently affected as males. 

The affection is neither related to rheumatism nor gout. 

It was formerly held, that the disease was dependent on 
lesions of the spinal cord owing to the occurrence of muscular 
atrophy, pain, neuritis, increase of reflexes, etc., but the 
modem theory is in favor of a chronic infection resulting 
from gonorrhea, influenza and other infectious diseases. In 
children^ Still has described a form characterized by en- 
largement of the joints and swelling of the lymph -glands 
and spleen. The onset usually occurs before the second 
dentition and girls are more frequently affected than boys. 
The children are puny and show arrest of development. 

105 



S p 



d 



I 



r a p y 



Nathan'" describes a metabolic form of ostcu -arthritis 
which is characterized by a symmetrical involvement of many 
joints with swelling and increasing deformity. Radiograms 
show a peculiar punchcd-out rarefaction in the early stages, 
and absorption and distortion in the late stages without the 
presence of proliferative processes or bony ankylosis. It is 
interesting to observe that in such cases the employment of 
the thymus shows a remarkable effect. One begins with two 
five-grain tablets thrice daily, In a couple of weeks the 
dose is increased to three tablets and after a month three 
tablets four times a day are given, 

A loxemic faclor has been recognized in the etiology of 
arthritis deformans and treatment directed toward a pyorrhea 
alveolaris or albuminous putrefaction of the intestines has 
been followed by satisfactory results. In the latter condition, 
indicanuria is present. Intestinal putrefaction is combated 
by interdicting meat in the diet, the use of intestinal anti- 
septics, the employment of laxatives to produce daily move- 
ments of the bowels and the use of soured milk (one or two 
pints daily). The latter may be substituted by tablets 
containing lactic acid bacilli, butcare must be taken that the 
products are reliable.* 

It is the VERTEBRAL form of this affection which is of 
particular interest to us. Here there is a progressive 
ankylosis of the vertebra- conducing to spinal rigidity (poker- 
back). This condition has been described as spondylitis 

■ORMANS.of which there are two varieties; that of Von 

ihterew, which is either hereditary or secondary' to a 

1 in which nerve-root symptoms (anesthesia, pain and 

atrophy) predominate and the spine alone is 

In the Strumpell- Marie type, also known as 

ore hilly discussed on pagr {44. 




O s t e "Arthritis 

SPONDYLOSE rhizom£lique, the spinal signs are less char- 
acteristic and the shoulderrjoints may be involved as well as 
the hip. 

When the spine in the lumbar region is involved, the 
pains may simulate sciatica or lumbago; in the cervical 
region the pains are referred to the neck and arms and in 
the dorsal region along the intercostal nerves. 

My friend, Dr. S. J. Hunkin, who has had an extensive 
experience, contends that probably most lumbagos and 
sciaticas are of osteo-arthritic origin. Spondylitis deformans 
is about three times as frequent in men as in women and the 
ages of predilection are from twenty-five to forty -five years. 

The laborer's spine (duplicature champetre of Marie), 
occurring in laborers who must adopt the stooping posture, 
must not be confused with this aflFection. In the laborer's 
spine, the entire spine is never "welded together" and there 
is no exostosis nor decided ankylosis of the joints of the 
extremities. 

In the diagnosis of osteo-arthritis, mention has been 
made of the x-ray plate for revealing the osseous overgrowth. 
The latter may also be revealed by palpation, which shows 
thickenings or nodes. 

If the aflFection implicates the spine, the range of motion 
is limited and the lordotic curve instead of ending at the loth 
or nth dorsal vertebra, runs up to the 7th or 8th dorsal 
vertebra or perhaps higher (Hunkin). Involvement of the 
vertebrae is further noted by limitation of the hip -movements 
and stiflFness of the back. The normal curves are accentu- 
ated, notably the lumbar and dorsal ones, and the patient is 
bent in walking. If there is any ankylosis between the ribs 
and the spine the breathing is abdominal, owing to deficient 
expansion of the chest. Diminution or absent chest-expan- 
sion shows implication of the articulation of the ribs. 

107 



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I 



t h 



r a p y 



If there is any motion in the spine it is painful and may 
be associated witti crepitus. It is necessary to distinguish 
loss of motion due to muscular spasm and locking of the 
joints by the osteophytes. 

Little nodules (Heberden's nodosities) may be felt upon 
the sides of the distal phalanges. 

Although thisdisease is regarded as incurable, //ttosiMamin 
may be tried or anesthesia employed. 

Fibrolysin is preferable to thiosinamin and is used 
hypodermatically. The drugs in question soften scar tissue. 

Anesthesia is effective for a dual reason ; if the ankylosis 
is fibrous it may be forcibly overcome. 

Again, Marshall" has recently shown the following re- 
action after ether-anesthesia in the usual manner from a cone 
for fifteen minutes in ostco -arthritis without apparent in- 
fection; complete subsidence of pain, restored motion in the 
involved joints and partial disappearance of periarticular 
swellings. Amelioration may not occur for twenty -four 
hours and the relief between anesthesia and the return of 
pain is from two days to two weeks. Acute, show more 
decided changes than chronic cases. If the patient is made 
worse by the anesthesia the arthritis is probably of infectious 
origin. The therapeutic value of repeated anesthesias wtt 
not determined, owing to the insufficient number of cases. 

Relief of pain in the early stages of the disease is secure 
by fixation of the spine, but later, such immobilization is 
not indicated owing to ankylosis, which must be prevented 
by active and passive movements. 

pott's disease of the spine. 

This refers to a progressive tuberculosis of the vertebra 
bodies or discs, eventuatirtg, as a rule, in ankylosis and k}'ph- 
osis. The disease is localized in order of frequency i 
follows : 

108 



tious 

']■ 

ureo^^ 

in is 
nted 

bral^^^ 



t t ^ s Disease 

— ^■'^^-^— — — '^— — — ^— — ^— — ^^^— ^— 

I. — Dorsal; 

2. — Lumbar; 

3. — Cervical portion of the vertebral column. 

The great majority of cases occur before the age of four- 
teen years and one or several vertebrae may be simultaneously 
involved. The disease is equally common in the male and 
female. Heredity, traumatism and the diseases of children 
which enervate the vitality, are frequent etiologic factors. 

The tuberculous lesion in this disease is usually located 
in the body of the vertebra leading to disintegration of the 
osseous structure which may terminate in caries or suppura- 
tion. In consequence of softening and absorption of the 
vertebrae they cannot sustain the superimposed weight, hence 
deformity (kyphosis) results. 

When the disease involves the last vertebra, the deformity 

resulting causes the lower lumbar vertebrae to project over 

the brim of the pelvis like a roof [yide spondylolisthesis). 

Muscular spasm is an early and characteristic symptom 
manifested by anomalous attitudes, lateral deviations of the 

column and reduced flexibility of the spine. 

Muscular rigidity is so important an early sign that the 

following rules of Lloyd ^^ are apropos: 

1. If stiffness is present when the patient is told to nod 

the head afl&rmatively, there is occipitoatioid 
disease. 

2. If stiffness is noted when the patient is directed to 

look far to the right or to the left, there is atio- 
axoid disease. 

3. When the shoulders are firmly fixed to the back of 

the chair and the eyes are carried back along the 
ceiling, any stiflfness suggests disease below the 
second cervical vertebra. 

4. Place the patient prone on the lap and indicate the 

tip of each spinous process with a pencil, after 

109 



^ 



whiL"h dircci ihe child to stand -itraighl and note 
il any of the iieodl-marks approximate; if iwo 
or more marks do not approach each other ap- 
proximation is prevented by rigidity and the 
disease is in the dorsal region. 
S- To delect lumbar rigidity, place the nude patient 
upon a couch and grasp the ankles and raise the 
pelvis. If the lumbar spine is 6exible the pelvis 
is lifted without raising the chest from the couch 
and the movement deepens the hollow of the 
loin. If the lumbar spine, however, is stiS, the 
trunk is raised and there is no alteration of the 
outline of the lumbar spines. In Pott's disease, 
when the child is directed to pick up an object 
from the floor, the knees (not the back) are bent. 

Pain, usually dull, may be located at the site of the 
disease or referred to the peripheral distribution of the 
irritated nen'es, and it is for the latter reason, that the child 
may be treated for some visceral affection. 

Bilateral pains (sciatica and intercostal neuralgia) are 
suggestive of vertebral disease and chronic bilateral belly- 
aches in children are diagnostic according to Lloyd. Pain 
and tenderness in the back suggest abscess-formation. Very 
often the pain of dorsal disease may be assuaged by raising 
the shoulders and in cervical disease by lifting the head. 

Deformity, especially when angular and in the median 
line, is pathognomonic of this disease. Angular deformitv 
is noted more often in regions where the normal curves are 
posterior than when they are anterior. 

A skiagram is invaluable in the early diagnosis of Pott's 
disease. 

When the disease has subsided, there is no longer any 
tenderness of the spine to vertical pressure, and jarring of 
the column in various ways causes no inconvenience. Rigidity 



Sacro-Iliac D 



t s e a s e 



may continue as a result of the welding together of the 
affected vertebrae. 

In adults and less often in children, Pott's disease may 
occur without deformity and the only symptoms may be 
the signs of a spinal abscess and implication of the cord 
and spinal roots. 

SACRO-ILIAC DISEASE. 

. S5monyms. — Sacro-coxitis ; Sacro-coxalgia. 

This is either an acute or chronic tuberculous disease of 
the sacro-iliac articulations,* commencing either in the 
S5movial membrane or bone, and is practically identical with 
Pott's disease of the spine. It occurs most frequently in 
early adult life and the predisposing cause is identified with 
occupations (equestrians) exposing the joints to traumatism. 

The pain in this disease may be confined to the aflFected 
joint or may be referred to the distribution of the dorsal or 
sciatic nerves. It usually begins on getting up after a night's 
rest and is accentuated by all movements which jar the 
joint. Examination per rectum will reveal tenderness over 
the joint. The pathognomonic sign is the following : pain 
in the joint when the sides of the pelvis are pressed together. 
In walking, the steps are cautiously made to avoid all jars 
to the joint and the patient walks chiefly upon the ball of 
the foot and the body is inclined toward the sound side 
with tilted pelvis. Examination of the joint shows swelling 
and elevation of local temperature. 

SACRO-ILIAC RELAXATION. 

The sacro-iliac joint is a true joint and may be the site 
:he same diseases as other joints . 



of the same diseases as other joints 



♦The two superior posterior spinous processes of the ilium are on a line with the 
third sacral spine, below which are the sacro-iliac joints. 



Ill 



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d 



I 



Goldthwait/" refers many backaches in women to 
luxation of the sacro-iliac joints. Even in the norm, the 
latter show definite motion which, during pregnancy and 
menstruation, is augmented. These joints are also relaxed 
in consequence of traumatism and general weakness. The 
so-called "stitch" in the back, from strain or overwork, 
represents a strain of the joint in question. The backache 
occurring in the morning after sleep and after operations is 
referable to the general relaxation following the dorsal 
posture which strains the lumbar spine and draws the sacrun 
backward. 

It is suggested that the backache thus produced is com 
monly relieved by stretching upon first waking, which drawl 
the lumbar spine for\vard. 

Drag of the abdomen in obese Individuals is often \ 
source of sacro-iliac weakness in consequence of the lordos 
and pelvic-joint strain. 

The most frequent symptom in sacro-iliac relaxation i 
backache referred either to the sacro-iliac articulations c 
the sacrum. The backache may develop during sleep, owing 
to the recumbent posture. The lumbo-sacral cord passes 
directly over the upper part of the sacro-iliac articulation 
and the pressure thus induced accounts for the referred pains 
in the lower extremities. Objectively, one may note when 
the patient stands, an obliteration of the lumbar curve ofj 
the spine. I 

The diagnosis of sacro-iliac relaxation Is often made \sf\ 
the therapeutic results. Thus relief at night is attained by 
lying on a firm bed with a firm hair-pillow under the hollow 
of the back. If the joints are strained or only relaxed, some 
support to the pelvic bones, like adhesive straps or a wide 
webbing belt fixed to the base of the corsets and kept up 
by the insertion of light steels, may be employed. 



spinal Curvatures 

luxation of the upper part of the sacrum is present, it may be 
corrected by extending the spine; legs on one table and 
head and shoulders on another table with the face downward 
and the unsupported body hanging between. After this 
manner, the sacrum is replaced and a plaster-jacket is 
applied. 

Sacro-iliac relaxation is frequently confounded with 
sciatica and lumbago. It is diflFerentiated from the former, 
1^ the absence of pain on pressure along the sciatic nerve 
and from the latter, by the absence of pain on pressure over 
the lumbar muscles and free motion of these muscles. In 
the diagnosis of relaxation of the sacro-iliac joint, one must 
not forget that a rectal examination will often reveal a tender 
point on either or both sacro-iliac joints. If certain move- 
ments cause pain and the cause is sacro-iliac relaxation, 
the same movements may be made without pain during the 
time the sides of the pelvis are compressed by the hands of 
the physician. 

SPINAL CURVATURES. 

The curves of the normal spine have already been dis- 
cussed (page 39). The chief varieties of curvature are: 

1. Scoliosis or lateral curvature. 

2. Posterior curvature, also known as kyphosis, gib- 

bosity or excurvation. 

3. Lordosis or anterior curvature. 

4. Angular curvature from caries of the spine. 

SCOLIOSIS. 

This refers to a lateral deviation of the spinal column 
with or without rotation of the vertebrae on their vertical 
axes. 

Scoliosis is the most frequent of all orthopedic aflFections 

113 



and is more common in girls than in boys (four to seven 
girls to one boy). 

The largest percentage of cases occurs before the age of 
fourteen years and very few cases occur thereafter. 

The most frequent curve is toward the right in the dorsal 
region, owing to the fact that the right Is used more often 
than the left arm. 

Scoliosis is usually acquired and the most frequent causes 
are general muscular debility and rickets. 

Scoliosis may result from an empyema with adhesions 
and the concavity of the curvature is toward the affected side. 
Caries and spinal tumors may eventuate in scoliosis. 

In SCIATICA, scoliosis is frequent, the body being In- 
clined toward the healthy side (convexity of the spinal 
column toward this side) or, more rarely, the trunk is inclined 
toward the affected side, or even more rarely the trunk 
may alternate in being inclined toward one side and again 
toward the other side (alternating sciatic scoliosis). The 
probable cause of scoliosis in sciatica is unilateral reflex 
contractures of the muscles of the back. 

Other varieties of scoliosis are: 



^^^^^ It is not difficult to recognize scoliosis when all the 

W clothing is removed and the child stands. Scoliosis is made 



Habit scoliosis, due to habitual faulty positions, 
and in this category may be included vocational 
scoliosis resulting from faulty postures during 
occupation and observed in dentists, barbers, 
dressmakers and others. 

Static scoliosis, due to inequality as a result of 
alterations in the extremity. Thus, in shortening 
of one leg an obliquity of the pelvis results in 
the opposite direction with a primary deviation 
of the lumbar vertebrje. 




spinal Curvatures 

evident by marking the spinous processes with an anilin 
pencil. Numerous scoliosometers are used for measuring 
and recording the degree of the deformity. 

It may happen that in neurasthenics, the spines of the 
vertebrae are tender on pressure and here mistakes arise in 
the incorrect diagnosis of spinal caries. In the latter 
aflfection, spinal rigidity is the essential factor in diagnosis 
due in the early stages to involuntary muscular spasm and 
in the latter stages to ankylosis. 

When the spine is flexible and curvature can be combated 
by manipulation, the case is one of scoliosis. Scoliotic curves 
however, may be rigid, but only after having been present 
for many years. 

There are cases of functional lateral deviation of the 
spine which are easily corrected and must not be confused 
with true scoliosis. In the latter, flexion of the spine in- 
creases the deformity and in the former it is obliterated. 
Functional deviation, if neglected, may be converted into a 
true scoliosis. 

Respecting prognosis in scoliosis one may say, that when 
there is no deformity of the bones, i, e., when the physician 
can by traction and manipulation, correct the deformity, 
and when the spinal muscles are intact, a cure can be pre- 
dicted. There is no antagonism between scoliosis and tuber- 
culosis as was at one time supposed. 

If scoliosis is caused by a shortened extremity, a thick- 
soled shoe is indicated. Muscular nutrition is effected by 
correct exercises, massage, electricity and central sinusoidali- 
zation (page 158). 

KYPHOSIS AND LORDOSIS. 

When the normal dorsal curve is increased it is known 
as kyphosis or posterior curvature, and increase of the 

lis 



S p ondylotherapy 

lumbar curvature is called lordosis, anterior concavity or 
saddle-back (Fig. 37). Compare the latter with Fig. 16 
showing the divisions and contour of the normal spine. 

Kyphosis and lordosis may co-exist. Lordosis is fre- 
quently an act of compensation to counteract the center of 
gravity going too far forward. This compensatory lordosis 
is noted in pregnancy, in obese individuals, from abdominal 
enlargement, in rickets, etc. 

A paralytic variety of lordosis is observed in muscular 
atrophy and pseudohypertrophic paralysis. 




Fig. 37. — A, increase of the dorsal curve or kyphosis; B, increase of the 
lumbar curve or lordosis. 

Adolescent kyphosis is frequently noted in young women 
who have been overworked in the workshop or field. 

As a rule, the deformity cannot be overcome by voluntary 
eflFort, and, in consequence of compensatory changes in the 
bones, it becomes permanent. 

Muscular kyphosis may result from muscular weakness 
due to faulty attitudes and is observed in tailors, carpenters, 
shoemakers and others. 

Senile kyphosis is caused by absorption occurring in the 
intervertebral discs. 

Rachitic kyphosis is most pronounced in the lumbar 
region and disappears in the recumbent posture and in 
suspension. 

116 



S p n 

In all recent cases of kyphosis, the deformity disappears 
when the patient lies upon the stomach. 

Kyphosis is diflFerentiated from the angular curvature of 
spinal-caries by the absence of rigidity of the spinal-muscles 
and pains when the vertebral column is percussed. 

Lumbar bulging must not be confounded with kyphosis. 
It is usually a swelling on either side of the spine and is 
commonly associated with some renal affection (tumors, 
pyonephrosis, etc.). 

ANGULAR CURVATURE. 

This may result from any disease of the vertebral bodies, 
notably, tuberculosis, osteomyelitis, syphilis, secondary 
carcinoma of the vertebrae, etc. Insomuch as this condition 
usually results from tuberculous caries of the vertebral 
bodies, the reader is referred to the description of Pott's 
disease (page io8). 

SPONDYLITIS. 

Spondylitis deformans has already been described 
(page io6). 

The vertebrae are implicated in various diseases usually 
of infectious origin. The following forms of spondylitis 
may be diflFerentiated. 

I. Traumatic spondylitis. — This aflfection follows an 
injury and bears a close resemblance to Pott's disease. The 
vertebrae between the 3rd and 7th dorsal are most frequently 
implicated. The pain which is present may be located in 
the injured area or may be referred, and is accentuated by 
pressure and movements. Kyphosis may also be present. 
The injury may be associated with fracture and the spinal 
cord may be ultimately involved in this aflFection. Whereas 
traumatic spondylitis is non -tuberculous, it must not be 

117 



forgotten that Pott's disease may follow traumatism. In 
tuberculous disease of bone, here as elsewhere, the injury- 
creates an area of least resistance in which the bacilli are 
deposited or a latent area of tuberculosis may be aroused 
into activity. 

2. Infectious spondylitis.— This is observed in actino- 
mycosis, syphilis, gonorrhea, osteomyelitis and typhoid fever 
(page 121 ). 

SPON D VLOLISTHESIS. 

This refers to a deformity of the spinal column produced 
by the gliding forward of the lumbar vertebrae in such a way 
that they overhang the brim of the pelvis and obstruct the 
inlet of the latter (spondylolisthetic pelvis). 

It is an uncommon affection and results from malforma- 
tion, strain or violence. 

The diagnosis is established by : 

I. A history of injury during the developmental period 

with pain in the lower part of the back. 
3. Shortening of the body in the lumbar region. 
3. Lordosis with separation of the ilia. 

A like deformity of the pelvis known as spondylizema 
is produced by caries of the last lumbar \'ertebra and the 
top of the sacrum. 

TRAUMATISM OF THE SPINE.* 

It is an undeniable fact, that spinal injuries may prove 
an exciting factor in the development of many chronic 
diseases, notably, general paralysis of the insane, locomotor 
ataxia, etc. 

Whether traumatism can be regarded as a cause of the 
latter affections is still a debatable question insomuch as 



*Vidt liligation backs (page 97) and 




S p 



I T 



r a u m a t t s m 



they may have existed unrecognized prior to the injury. 
Schlesinger, shows that the symptoms ascribed to a traumatic 
neurosis may be due in many cases to some pre-existing 
affection. He examined one hundred victims of various 
accidents within ten days of the accident and was amazed 




Fig. 38.— Relation of ihc spinal cord 10 ihe 




es. V, bodv 




. vessels; 3, dura mi 


Iter with th( 


arachnoid Iving direclly benealh 11; 4, anienor 


root; s, posterior re 


ot; 6, spinal 


ganglion; 7, ligament (Dana). 







at the large proportion of pathologic conditions found. Only 
twenty-two of the one-hundred persons were found normal. 

It is likewise difficult to dissociate true from fictitious 
nervous symptoms following a simple strain which is often 
associated with the term traumatic lumbago (page 103). 

A spinal sprain may resuh from direct or indirect in- 
juries and the lumbar region is usually involved. According 
to the nature of the injury spinal sprains may be differen- 
tiated as follows : 

119 



Simple sprain. 

Sprain with nervous symptoms. 

Sprain with spinal cord symptoi 



The relation of the spinal cord to the surroundii 
structures may be noted in Fig. 38. 

A simple sprain is pathologically associated with some 
injury to the spinal-muscles and ligaments or both. The 
dominant symptom is pain moderated by rest and accen- 
tuated by motion. The spinal -muscles are in a condition 
of compensatory spasm to immobilize the vertebral column. 
Areas of tenderness may be present and simulation of pain 
may be excluded by the signs of Mannkopff and Loewi 
(page 70). 

Nervous symptoms, usually neurasthenic or hysterical 
in character, may co-exist with the symptoms of a simple 
sprain and when cord-symptoms (paralysis, anesthesia, 
changes in the reflexes, girdle pain and sphincter-changes) 
follow the sprain, one must suspect concussion of the cord 
(when the symptoms abate within a week), hemorrhage 
within the cord (hematoroyelia) or the development of a 
meningitis. 

Simulation is a constant factor in spinal injuries zind in 
diagnosis one must not forget Charcot's conception of a 
trauma in etiology. The latter taught that functional 
symptoms following an injury, were related to like symptoms 
which could be made to appear and disappear by hypnosis. 
The shock of an injury is tantamount to an hypnotizing agent 
(suggestion) which directs the attention of the patient to 
the injured part and suggests the symptoms {traumatic 
suggestion). 

There are many neurologists who assume that the sym] 

toms of a traumatic neurosis can be produced by one idi 

and removed by another idea, in other words, all is refei 

120 



M 



T y p h id Spine 

to suggestion and that there can be no purely functional 
troubles in the absence of anatomic lesions. 

Osteopathic traumatism. — In the author's experience, 
the mechanic manipulations of many osteopaths often 
conduce to severe spinal sprains for, if the osteopath regards 
a dislocated vertebra as the cause of disease or supposes 
that a vertebra is compressing a vessel or nerve, he is in- 
clined to conciliate his conviction with more force than 
discretion. 

TUMORS OF THE SPINE. 

Tumors of the spine are usually carcinomatous and less 
frequently sarcomatous. Carcinomata are rarely primary. 
They are secondary in nature and due most frequently to 
metastases from carcinomata of the breast and occur there- 
fore with greater relative frequency in women. 

Secondary deposits in the lumbar spine are relatively 
frequent in individuals with cancer of the breast and a group 
of symptoms designated by the term paraplegia dolorosa 
accompany the deposits, viz., lancinating pains, hyperes- 
thesia and occasionally paralysis of the bladder and rectum. 

In malignant disease of the spine the following are 
characteristic signs : rapid course, cachexia, local tenderness 
and severe pain, deformity, rapid emaciation and anemia, 
absence of fever, paraplegic symptoms, antecedent history 
of a malignant growth and localization in the lumbar region. 

The iso-hemolytic power of the serum may yet serve of 
diagnostic value as a characteristic reaction of cancer. 

TYPHOID SPINE. 

Bone-lesions (periostitis, caries and necrosis) are occa- 
sional sequelae of typhoid fever. 

In 1889, Gibney described a condition of the spine 

121 



Spondylotherapy 

occurring* during the course of the disease in protracted 
rases and more often during convalescence, in which pain 
is felt either in the lumbar or sacral regions, especially after 
a slight injury or shock. Usually the condition is a neurosis 
with a good prognosis, but in rarer instances, the pathologic 
process may be a periostitis with or without a subperiosteal 
abscess or spondylitis. 

Among the symptoms are stiffness, localized pain and 
weakness of the back. 

The total number of cases thus far reported is about 
seventy-four. 

VERTEBRAL INSUFFICIENCY. 

This condition has been described by Schanz in indi\nd- 
uals between the ages of 20 and 40 years who complained 
of severe pains in the back. The spinous processes of the 
vertebrae are painful on percussion and the bodies of the 
lumbar vertebrae are equally sensitive. The latter is 
demonstrated by deep abdominal palpation when the fingers 
attain a point where the pulsations of the abdominal aorta 
are perceptible. Another sign is the difficulty experienced 
in changing the dorsal for the ventral posture. 

\'ertebral insufficiency is frequently regarded as an 
expression of neurasthenia and often it has been misin- 
terpreted as a tuberculous spondylitis, but the immediate 
results of the treatment exclude neurasthenia and spondy- 
litis. Some of the patients date the symptoms from the 
moment corsets have been discarded. The treatment con- 
sists of rest, massage and particularly the use of an orthopedic 
corset. 

Orthostatic alboilnt-ria. — In this affection, which 
occurs most frequently in children, albuminuria is present 
when the patient is up and alx^ut but disappears after rest 
in Ixxl. The condition is not associated with nephritis. 

Ml 



M al-Alignment 

Jehle'* regards lordosis as an invariable concomitant of 
this condition and he has induced albuminuria in healthy 
children by provoking a curvature of the spine. It is sup- 
posed that the incurved vertebrae protrude into the space 
between the kidneys, thus twisting them around on a vertical 
axis and causing circulatory disturbances. It is further 
assumed that when the children are up, the weakness of the 
spinal muscles causes a lordosis. The albuminuria may be 
corrected by a supporting corset or by strengthening the 
muscles of the back and by making the sole of the shoe a 
little thicker. 

MAL -ALIGNMENT OF THE CERVICAL VERTEBRAE. *^^ 

As observed on page 42, our conception of the movements 
of the spine is too limited and if the current opinion is enter- 
tained, that the vertebrae are firmly bound together to form 
an elastic whole or entity, it is impossible to credit such a 
condition as mal-alignment of the cervical vertebrae without 
the presence of a traumatic dislocation. 

Bates** observes, "the muscles are designed and attached 
to each vertebra so as to enable it to contribute its propor- 
tionate share to any of the movements of the neck as a whole, 
and this arrangement guarantees it a certain amount of 
individual mobility; which is needed for the execution of 
the more complicated motions of the head and neck.'' 

Reference has been made on page 47 to the author's 
observations on spasm of the spinal musculature provoked 
by peripheral sources of irritation. The muscles, in a 
condition of spasm by exercising traction on the cervical 
vertebrae, may force them out of the normal alignment. 

Now the osteopath contends that, in consequence of the 
spasm of the muscles and mal-alignment of the vertebrae, 

123 



compression of the vessels and nerves ensues which conduces 
to definite s>'Stemic anomalies. 

The recognition of cervical spasm and mal-alignment is 
not difficult. The former may be recognized by palpation; 
the muscles are painful and in a condition of contraction. 

Mal-alignment is noted by deviations from the normal 
articular line of the head and vertebral column. 

Dr. Geo, Gould comments on the frequency of mal- 
position of the head, torticollis and spinal curvature due to 
eye -strain. 

The author has noted even in the norm that, when the 
physician directs a patient to make strained movements of 
the eyes (without moving the head), and at the same time 
palpates the muscles of the neck on either side of the spine, 
the muscles in question contract spasmodically. It is not 
difEcult to conceive then that, if the peripheral irritation is 
persistent, the muscles can pass into a state of tonic con- 
traction.* Now a bit of conservatism is necessary in 
estimating the results attained in the treatmentof these cases. 
It is difficult to conceive, at least, theoretically, how any 
manipulation of the muscles will bring benefit until the 
source of peripheral irritation is eliminated. However, one 
must regard with tolerance the observations of those who 
contend that relaxation of the contracted muscles and re- 
leasing "locked out vertebrx" suffice to cure. 

For the sake of completeness, the author desires to 
describe the methods employed by osteopaths for the 
"adjustment of muscular lesions" and the "adjustment of 
cervical vertebrae.* " 

*Dr. Louis C. Deane, recently referred a patient to mc foi diagnosis, who in con- 
sequence of a severe injury to the head, suffered (rora diplopia and vertigo. 
The condition was one of muscular asthenopia. In this patient the muscles 
of the neck were in a state of tonic contraction and the head almost approxi- 
tnated Ihe shoulder. Suggestion made during hypnosis sufficed to remove 
the diplopia after a single stance and when corrected the head was again held 
in a nonnal position. 



J^ertebral Adjustment 

ADJUSTMENT OF MUSCLES. 

1. Pressure with quiet and slight rotation usually in a 
direction at right angles to that of the muscular fibers. 

2. Relaxation is attained by stretching the muscle with 
the object of separating the origin and insertion of the muscle. 

3. By approximating the origin and insertion of the 
muscle. 

The foregoing methods are infrequently employed alone, 
but are usually used in combination. 

ADJUSTMENT OF CERVICAL VERTEBRAE. 

1. With the patient in the recumbent posture, the 
physician at the head of the table grasps with the fingers of 
each hand the tissues along the region of the arches of the 
vertebrae with the thumbs on the transverse processes ; the 
lesion is exaggerated by pushing with the left hand directly 
to the right the tissues overlying the lateral arches; simul- 
taneously the patient's head is forced against the abdomen 
of the physician to steady the movement. Next, reverse 
pressure is applied over the right lateral arch and rotation 
is achieved by movement of the hands and body of the 
physician. 

2. With the patient in the same position as in the fore- 
going method, pressure is effected after the same manner 
but the fingers on one side and the thumb on the opposite 
side grasp the postero-lateral arches and with the hand 
upon the crown of the head, manipulation is made for 
purposes of rotation. Pressure isTnade downward upon the 
head in the direction of the axis of the vertebral column so as 
to fully relax the muscles and other tissues. 



125 



Spondyio 



CONGESTION OF THE SPINAL CORD. 

According to some authorities, areas of vertebral tatderness 
are associated with congestion of the spinal vaso-motor 
centers. The pathologist, however, is unable to confirm this 
clinical observation. On the contrary, anemia does cause 
changes in the cell-bodies of the cord with degeneration. 
It is an undeniable fact that, any interference with the 
motions of the spine resulting from weakness of the spinal 
musculature is associated with venous stasis which must 
necessarily interfere with the nutrition of the cord. The 
spinal muscles in the lumbar region are supplied by the 
lumbar artericsand in the dorsal region by the intercostal 
arteries. Branches from these vessels enter directly into the 
spinal canal on a level with each vertebra. 

The SPINAL VEINS have no valves. The venous plexuses 
upon and within the spine are as follows : " i . Those placed 
on the exterior of the column {dorsal spinal veins); 2. 
Those located in the spinal canal between the vertebrae and 
the membranes (meningo-rachidian veins); 3. The, 
veins of the vertebral bodies; 4. The veins of the spinj 
cord (Fig. 39). 

DIAGNOSIS OF SPINAL DISEASES. 

In the differential diagnosis of spinal diseases the genes 
of PAIN* and DEFORMITY must be determined. Then c 
must decide if the membranes and spinal cord are implicate 
and also the character of the lesion. The following tab! 
will aid in the differentiation of pain and deformity. 



I 




*Vide backaches and lumbago (pages 83 and 99). 




Fig. jt). — The upper figure represents the trinsverse section of a doraal 
Tcrteh™ showing the spinal veins. The lower figure is a vertical section of two 
dorsal veriebrs showing the spinal veil 



4^ P 



n 



t h 



r a p y 



^B 



PAINS. 



DISEASE. 



Aneurism (thoracic) 



Compression myeutis. 



Hip-joint disease. 



concomitant symptoms. 



Sharp paroxysmal lancinating pains 
when the aneurism erodes the 
vertebrae. Pain radiates down 
the left arm, to neck and up- 
per intercostal nerves. Also 
anginoid pains. Signs of intra- 
thoracic pressure. In spinal 
curvature, dislocation of the 
heart may cause displacement of 
the aorta, causing the latter to 
pulsate to the right of the 
sternum. 

Nerve-rooi symptoms, — Radiating 
pains, anesthetic areas, trophic 
disturbances and atrophy of the 
muscles. 

Cord symptoms. — Cervical reigon — 
Retropharyngeal abscess, spasm 
of the cervical muscles, dilatation 
of the pupil and unilateral flush- 
ing or sweating. 

Thoracic region. — Paraplegia of 
the spastic type (exaggerated 
reflexes) and when the com- 
pression is complete (rare), re- 
flexes are abolished. 

Lumbar region. — Paraplegia with 
implication of the sphincters. 

Often confounded with lesions of 
the lumbar region. Pain in hip, 
front of thigh, or at inside of 
knee. Limitation of motion of 
the hip-joint, unilateral atrophy 
of the muscles (especially the 
adductors) , lameness, swelling 

128 



S p 



n 



a 



a 



n 



DISEASE. 



Intraspinal tumors. 



Lateral curvature. 



Leukemia. 



Lumbago. 



concomitant symptoms. 

confined to the front and back o( 
hip-joint and attitude of limb 
(abducted and everted). 

Symptoms vary with the segment 
involved. Radiating pains from 
the level of the lesion. Usually 
paralysis of the leg on one side 
and sensory disturbances on the 
opposite side and jerking move- 
ments of the lower extremities. 
A radiogram may show infiltra- 
tion of the vertebrae by the 
growth. At the level of the 
growth, pressure at the side of 
the spinous processes may elicit 
the pains felt by the patient. 

Severe cases in the lumbar region 
may simulate malignant disease 
of the spine. The latter is ex- 
cluded by the long duration of 
the disease absence of cachexia, 
presence of compensatory curves 
and the unilateral deformity. 

The sternum and spinal column 
are exquisitely tender on pres- 
sure. 

Usually occurs after a sudden 
muscular effort in a gouty or 
rheumatic subject or after ex- 
posure to cold or wet. Patient 
usually in excellent health and 
pains yield as a rule to treat- 
ment. Lumbago resisting treat- 
ment may be symptomatic of an 
organic lesion of the spine 
(Pott's disease, tumors). 

129 



Spondyloth 



IBB 



r a p y 



DISEASE. 



Locomotor ataxia. 



Neuromimesis (Hysteria). 



Osteoarthritis. 



OSTEOMYEUTIS. 



Pleurodynia (Muscular rheu- 
matism of the intercostal mus- 
cles, pectorals and serratus 
magnus) . 



Sciatica. 



concomitant SYMPTOMS. 

Lightning pains usually of a few 
seconds duration are most com- 
mon in the legs and about the 
trunk. History of syphilis, 
ataxia, absence of knee-jerk, 
Argyll-Robertson pupil and sen- 
sory disturbances in the legs. 

The spinal symptoms (spinal irri- 
tation) of h3rsteria and neuras- 
thenia may simulate locomotor 
ataxia. The spinal tenderness is 
general, the pains are fugitive 
and evanescent and are not 
limited to definite anatomic ter- 
ritories. The patients are usually 
women and the history is corrob- 
orative. 

Vide spondylitis deformans (page 
1 06). 

Local symptoms of swelling and 
rigidity of the spine, constitu- 
tional symptoms of sepsis, 
sudden in onset and suppuration 
always occurs. Usually second- 
ary to some distant suppurative 
focus. 

Pain usually on left side and accen- 
tuated by breathing and cough- 
ing. Affected muscles painful on 
pressure. Often mistaken for 
pleurisy and intercostal neural- 
gia (page 186). 

A bilateral sciatica is always sug- 
gestive of a cord-lesion, notably 
pressure on the nerve-trunks of 
the Cauda equina. Sciatica is 

130 



S p 



n a 



I D 



f 



r m i t y 



DISEASE. 



Spinal meningitis. 



DISEASE. 

Acromegaly. 



Aneurism. 



Chondrodystrophia 
rickets). 



Maugnant 
spine. 



OsTEOMYEUTis (vertebral). 



CONCOMITANT SYMPTOMS. 

often secondary to a chronic 
arthritis of the spinal column and 
may be unilateral in the lumbo- 
sacral roots in Pott's disease. 

The root-oains are often con- 
founded with Pott's disease. In 
the latter disease, the root-pains 
are relieved by rest and accen- 
tuated by movement and the 
erect posture. In meningitis, 
there is a lymphocytosis of the 
cerebro-spinal fluid, whereas in 
Pott's disease (tuberculosis out- 
side of the membranes) the fluid 
is normal. 

DEFORMITY. 

CONCOMITANT SYMPTOMS. 

This dystrophy manifested by 
h)rpertrophy of the bones of the 
face and extremities is charac- 
terized by kyphosis. 

Deformity due to eroding into the 
bodies of the vertebrae occurs 
late in life and other symptoms 
of aneurism co-exist. 

Fetal Rigid kyphosis without spasmodic 
muscular contraction. Deform-, 
ity of the chest and premature 
ossification of the epiphyses of 
extremities. 

DISEASE OF THE Deformity absent or rounded with- 
out bursa. No suppuration, 
rapid course, cachexia, severe 
localized pain and paraplegia. 

Acute onset, rapid suppuration, 
constitutional signs of sepsis and 
rigors. 



Spondylotherapy 



DISEASE. CONCOMITANT SYMPTOMS. 

Facet's disease (Osteitis defer- The dorso-cervical kyphosis is 
mans). associated with forward projec- 

jection of the head, prominent 
clavicles, triangular-shaped face 
and shortening of the stature. 

Pott's disease (caries). Kyphosis is sharp and angular and 

usually gradual in development 
with muscular rigidity of the 
spine. 
Kyphosis as a rule, when not due 
to caries, shows soft erector 
spinas muscles and the absence 
of pain on concussion trans- 
mitted to the back. 

Pulmonary Osteoarthropathy Kyphosis may be present. En- 



(Hypertrophic). 



Rickets. 



Scurvy (Barlow's disease). 



Senility, 



largement of the articular ends 
of the bones, enlarged terminal 
phalanges and incurvation of the 
nails. Usually associated with 
pulmonary diseases. 

Kyphosis most pronounced in 
lumbar region and disappears in 
recumbency and suspension. 

Other signs: open fontanels, en- 
larged abdomen, rachitic rosary, 
enlarged epiphyses and deform- 
ity of the long bones. 

Kyphosis is not frequent in infan- 
tile scurvy and is associated with 
other joint-lesions, swollen gums, 
ecchymoses, swelling of the epi- 
physeal junctions and pain on 
moving legs and thighs. 

Kyphosis occurs in elderly p>ersons 
from flattening out of the verte- 
bral discs from pressure 

132 



C m p r e 



s s i n 



My 



t t t 5 



DISEASE. 



Spondylitis deformans (Rheu- 
matoid arthritis). 



Syphilis. 



CONCOMITANT SYMPTOMS. 

Occurs late in life with stiffness 
and arching of the spine without 
kyphosis, muscular spasm and 
suppuration. 

Congenital and acquired syphilis 
by causing kyphosis may lead 
to the erroneous diagnosis of 
Pott's disease, but syphilitic and 
not tuberculous symptoms are 
present. 



COMPRESSION OF THE SPINAL CORD. 
(compression MYELITIS). 

Spinal diseases may, or may not, be associated with 
interruption of the functions of the cord by slow compression. 
Among the causes of compression are the following : 



I 

2 

3 

4 

5 
6 



Caries (Pott's disease). 

Malignant growths (vertebral and retroperitoneal). 
Aneurisms. 
Syphilis. 
Trauma. 

Parasites in the spinal canal (echinococcus and the 
C3rsticercus). 



The symptoms of compression are : 

I. Vertebral. — Spinous processes tender on pressure, 
muscular rigidity of the spine and pain. The latter is 
accentuated when the spine is concussed or twisted. 

Kyphosis associated with vertebral disease is rarely the 
cause of compression, for the reason that the latter is more 
often the result of inflammation of the spinal meninges and 
the presence of inflammatory products between the involved 
vertebrae and meninges. The relation of the spinal cord 
to the surrounding structures is shown in Fig. 38. 

133 



S p n d y I t h e r a p y 

2. Nerve -ROOT symptoms. — Caused by compression of 
the nerve-roots as they emerge between the vertebrae and 
consist of pains in the region innervated by the nerves whose 
roots are compressed. 

Additional symptoms are : Sensory and trophic disturb- 
ances, herpes; and when the ventral roots are compressed, 
there is wasting of the muscles supplied by the affected 
nerves. 

3. Cord -SYMPTOMS.* — They are dependent on the 
region involved. 

i. Cervical region. — Retropharyngeal abscess, spasm 
of the cervical muscles, dilatation of the pupils, unilateral 
sweating and flushing of the face and paralysis of all four 
extremities. 

ii. Thoracic region. — Disturbances of sensation in 
the lower extremities, girdle sensations and pains in the 
course of the intercostal nerves and paraplegia (usually 
spastic) with exaggerated reflexes. 

iii. Lumbar region. — Paraplegia without exaggerated 
reflexes and involvement of the bladder and rectum. 

PARAPLEGIA. 

This is a symptom of many special diseases and may 
require a careful differentiation. Following a trauma, it 
occurs almost instantly or it may be partial and in the course 
of a brief period it may be complete as a result of a de- 
structive hemorrhage or from additional laceration of the cord 
from a fractured vertebra. 

The paraplegia associated with the following affections 
demands differentiation : 



♦The site of the lesion is easily determined (page 30). 

134 



Pa raplegia 

1. Rickets. 

2. Barlow's disease. 

3. Syphilis. 

4. Hysteria. 

i. Rickets. — The pseudo-paresis of this disease results 
from muscular weakness plus the pain caused by movements 
of the extremities. The muscles may atrophy from disuse, 
but there is no reaction of degeneration. The latter is also 
absent in cerebral paralyses but the reflexes are exaggerated 
and there are brain-signs and spasticity of the extremities. 

ii. Barlow's disease (infantile scurvy). — The pseudo- 
paralysis of this affection is likewise caused by muscular 
weakness and pain as well as by the subperiosteal extravasa- 
tion of blood which causes tenderness in the shafts of the 
bones. Scurvy and rickets may co-exist. In both affections 
the electric reactions are unaltered. In scurvy, antiscorbutic 
treatment (fresh cow's milk, meat -juice and orange-juice or 
lemon-juice) )nelds prompt results and, in this sense, it is 
equally diagnostic and curative. 

iii. Syphilis. — In children there is a syphilitic pseudo- 
paralysis known as Parrot's disease, in which sudden loss of 
motion may occur in either the lower or upper extremities 
or both and is caused by a separation of the cartilage at the 
end of the bone. Crepitation and pain follow movement of 
the affected extremity. 

iv. Hysteria. — The disturbances of motility are essen- 
tially paralyses of function or will-power. 

In one class of cases, movements like standing and 
walking are impossible, whereas all other functions may be 
executed by the same muscles. The reflexes are intact or 
exaggerated, the electric reactions are normal and there is 
no muscular atrophy. Symptoms of the bladder common in 
organic paraplegia are usually absent in the hysterical form. 

135 



L 



If the affected muscles offer any resistance to passive 
movements, it is suggestive of hysteria. 

Hoover's sign for the detection of malingering and 
functional paralysis of the lower extremities is as follows: 
In the norm, when a person lying on a couch on his back is 
requested to raise the right foot off the couch with the leg 
extended, the left heel digs into the couch as the right leg 
and thigh are elevated ; in other words, the left heel is used 
to fix a point of opposition. 

If a normal person is requested to press the right leg 
against the couch there will be a counter-lifting force shown 
in the left leg. This complemental opposition is present in 
the norm and in genuine paresis or paralysis (even though 
feebly expressed) but its absence in the malingerer and in 
hysteria signifies the existence of cerebral inhibition. 

The sign of Beevor'* is based on the fact that, in func- 
tional paralysis the patient is unable to inhibit the antago- 
nistic muscles. This condition is often noted in the knee and 
for this purpose the patient lies with the face downward and 
the leg is put up at right angles to the thigh and the patient 
is directed to extend the knee against resistance. In the 
norm the hamstrings should be relaxed at once, but in 
functional paralysis these muscles can be seen and felt to 
contract along with the extensors. The limb must be fixed 
and prevented from moving, otherwise as the joint is extended 
or flexed, the antagonists may be passively drawn on and 
give the impression that their muscles are actively con- 
tracting. 

Anesthesia from the waist downward without involvement 
of the genitalia is usual. The latter condition may be 
reversed ; anesthesia of the genitalia, whereas the other parts 
may retain their sensibility. 

According to Kahane, neuroses are favorably influenced 
136 




Nature o f L 



n 



by the high-frequency current, whereas hysterical subjects 
react unfavorably and new symptoms are added to the old 
ones even after a single application. In fact, latent hysteria 
has been detected after this manner. 

NATURE OF THE LESION. 
TUBERCULOSIS. 

Respecting the relative frequency of tuberculous joint- 
disease, the following statistics of Young'^ are apposite : 

Vertebrae 46.7 per cent 

Hip 34.4 " 

Knee 12.2 " 

Ankle 5.1 " 

Elbow 0.8 " 

Shoulder 0.5 " 

Wrist C.3 ** 

In etiology, a history of heredity is important. Acquired 
predisposition is developed in consequence of conditions 
which diminish resistance and predisposition to tuberculosis. 

Environment is a cogent predisposing factor. The 
absence of sunlight and fresh air predispose to infection. 

During the first decade of life, the bones, meninges and 
lymph-glands are more frequently involved. A surgical 
operation may convert a localized into a generalized tuber- 
culous process, notably, acute miliary tuberculosis. 

As a rule, practically all tuberculous joint-lesions are 
referred to some injury and all authors agree that only mild 
injuries result in tuberculosis. 

In severe traumatism, the process of repair is so active 
that the tubercle bacilli are destroyed. Experiments by 
inoculation confirm the latter clinical observation. Thus 
Krause, after inoculating animals with tuberculous material 
and then contusing the joints, obtained typical joint -lesions. 

137 




If. however, the traumatism were severe there was no second- 
ary involvement of the joint. 

Tuberculous involvement of the vertebrae usually occius 
during childhood (before the age of 14 years). 

Several joints may be simultaneously involved in tuber- 
culosis, notably, the hip and spine and the knee and spine. 

Asthenia, fever, night-sweats and emaciation are the 
characteristic symptoms of tuberculous infection. The x- 
rays may prove of some value in early diagnosis, but as a 
rule, the skiagram only demonstrates lesions which have at- 
tained some magnitude. 

Respecting the diagnosis of tuberculous lesions by aid of 
TUBERCULIN, the latter can only prove of value as a negative 
test (showing the absence of tuberculous foci in the body) 
and rarely as a positive test, owing to the fact, that vertebral 
involvement is usually secondary to a tuberculous lesion 
elsewhere in the body. 

The reaction with tuberculin is based on the fact,thatin 
tuberculosis the tissue-cells develop a hypersensitiveness to 
the poisons of the tubercle bacillus {allergislic reaction). 

In cachectic Individuals, in acute tuberculosis, and in all 
those far advanced in the disease, tuberculin tests are usually 
negative owing to the fact, that the organism is so over- 
whelmed by the poisons that it is unable to react. 

The tuberculin test may at first be negative, but when 
repeated it is positive. In such instances it is assumed, that 
there are latent tuberculous foci which have -not been in 
contact for a long time with the poisons of the tubercle 
bacillus and that the first test stimulates immunization which 
favors a reaction when the subsequent test is applied. A 
positive reaction with the sulx^utaneous method is obtained 
in from 50 to 80 per cent of clinically healthy individuals. 

In the presence of fever, the cutaneous or conjunctival 
138 



lus or conjunctival IJ| 



method is preferable to the original hypodermic method. In 
the latter the puncture -reaction (red area of infiltration, 
edema and pain at point of puncture) is even more diagnositc 
that the febrile reaction. The moro test is harmless and 
consists of rubbing into the unbroken skin of the abdomen 
a mixture of equal parts of tuberculin (old) and anhydrous 
lanolin. The rubbing should continue for about two or three 
minutes. The reaction, if positive, is manifested in from 12 
to 48 hours after the inunction by small papules and redness 
of the anointed area. The latter reaction is fairly reliable. 

The presence of tubercle bacilli in the circulating blood 
in tuberculosis, demonstrable after the simple method of 
Rosenberger,'' may prove of greater value in diagnosis than 
the tests with tuberculin. Many authorities, however, have 
been unable to confirm the observations of Rosenberger. 

Snow, finds that the employment of the static current 
gives prompt relief in non-infected joint-conditions, but 
produces negative results or aggravates the condition in 
tuberculous infections. 

Scrofula is an attenuated tuberculosis of the lymph- 
glands and practically in all cases of acute tuberculosis the 
source of infection is from unhealed foci in lymph -glands 
(tuberculous adenitis). 

SYPHILIS. 

Tardy hereditary syphilis of the bones may occur in 
adults, but is most frequent between the ages of 6 and 10 
years. 

The pains of this affection may be regarded as rheumatic 
and the associated syphilitic fever may suggest typhoid fever. 

The bones of the extremities are notably involved, usually 
at the shafts or in juxtaposition to the articulations, and 
5welling and deformity ensue. The tibia is most frequently 

139 



S p 



t h 



r a p y 




implicated, resulting in a forward projection of the bone 
(saber-bladed deformity). The surface of the bone may 
show irregularity due to the presence of nodes. 
Syphilis of the spine resembles Pott's disease. 
The following signs of congenital syphilis suggest the 
diagnosis : 

Nasal catarrh (snuffles). 

Depression at root of the nose. 

Cutaneous lesions. 

Fissures at the angles of mouth (rhagades). 
5. Alopecia (hair of head and eyebrows). 

Tardy development (infantilism). 

Deformed teeth, 

Interstitial keratitis. 

Ear-affections. 

The therapeutic test is fairly conclusive if employed with 
circumspection. Here nutrition must be maintained to gel 
the best results. 

Syphilis with lesions of the bones responds favorably to 
Gibbert's syrup: 

Biniodid of mercury 1 grain. 

Potassium iodid \ ounce. 

Water a ounces. 

Dose. — Five to ten drops three times a day gradually 
increased and continued for months. 
The Wassermann reaction is extremely valuable in the 
diagnosis of syphilis, but the reaction is too complicated for 
the practitioner and in consequence has been supplanted by 
the simplified method of Noguchi": To o.i c, c. of spinal 
fluid in a tube of not over i cm, diameter, add 0.5 c. c. of 10 
per cent butyric acid ; heat till bubbling and while hot add 
I c. c. of 4 per cent sodium hydrate solution. The fluid be- 
comes flocculent in a few moments, whereas normal fluids 
are only opalescent or cloudy. 
140 



« 




R h e u m a 



m 



GONORRHEA. 

Many obscure bone-lesions incorrectiy diagnosed as 
rheumatism owe their origin to the gonococcus, the result of 
systemic gonorrheal infection. 

Gonorrheal arthritis is characterized by involving joints 
which are not usually implicated in acute rheumatism, viz., 
sacro-iliac, intervertebral, temporo-maxillary and sterno- 
clavicular articulations. 

A history of gonorrhea suggests the character of the lesion. 

The employment of a gonococcic vaccine'* promises to 
prove of diagnostic value in gonococcic infections. The 
gonococcus reaction usually appears in from 8 to 12 hours 
after the injection and lasts about 24 hours. The most con- 
stant feature of the reaction consists of an increase of pain 
and tenderness in the affected joints and a slight pyrexia 
following the injection. 

It is well to recall the remarkable cures of gonorrheal 
arthritis reported by Fuller, who insists that the infectious 
material is derived from a gonorrheal vesiculitis and by 
opening and draining immediate relief of the arthritis occurs. 

RHEUMATISM. 

An acute arthritis deformans may be mistaken for acute 
rheimiatism and the diagnosis is often established when the 
affection has lasted for weeks and with subsidence of the 
fever, periarticular indurations and deformities persist. 

Implication of the smaller joints and the early deformities 
exclude acute rhemnatism. 

An acute osteo-myelitis may also be confounded with 
rheumatism, but the following signs are characteristic of 
osteo-myelitis : 

141 



S p n d y i 



t h 



It is most common in infants or children, i. e., during 
the period o£ active growth of bone. 

Severe constitutional symptoms of septic absorption. 

Involvement of the epiphyses rather than the joints. 

The condition is sudden in onset and pus forms 
rapidly. 

In osteo-myelitia of the vertebrae angular deformity 
is rare (differentiation from Pott's disease). 



The use of salicylates is a valuable aid in diagnostic 
pharmacotherapy. Failure in the treatment of rheumatism 
with the salicylates frequently results from their faultj' 
administration. The usual doses are absolutely inadequate. 

If sodium salicylate is given at regular intervals until its 
physiologic action is manifested (tinnitus or deafness), then 
stopping its use and resuming it when the latter have abated, 
usually on the second day there is a decided fall of temper- 
ature and relief from pain in acute rheumatism. The joint- 
swelling usually disappears by the fourth day. 

McCrae and Clarke have directed attention to the diag- 
nosis of various forms of arthritis by the use of salicylates. 
The true rheumatic can tolerate from 150 to 300 grains of 
sodium salicylate before toxic symptoms occur, whereas in 
other forms of arthritis such symptoms develop after smaller 
doses. Thus In gotwcoccic arthritis, the average amount to 
produce toxic symptoms was 131 grains. 

In true rheumatism, the fever, pain and swelling disappear 
in two or three days, whereas in other forms of arthritis, 
while the temperature may fall to normal, there is no change 
in the swollen joints. Doctor Lees, in a paper contributed 
to the Proceedings of the Royal Medical Society, also believes, 
that in most instances where the salicylates fail to relieve 
arthritis, the condition is not one of acute articular rheui 
tism but of some other form of infection. 
142 



R 



Rheumatism in children is unattended by typical joint- 
symptoms and a heart -lesion may be the only manifestation 
of the disease. The following signs may also suggest the 
disease in children: tonsillitis (initial symptom), growing 
pains, chorea, myalgia, pleurisy, frequent attacks of bron- 
chitis and anaemia. In children the salicylates must likewise 
be given in large doses : For a child of from 7 to 1 2 years, 
from 10 to 100 grains daily, and for a child under 7 years, 
from 5 to 50 grains daily, with twice the amount of sodium 
bicarbonate in each case. The latter drug is employed to 
counteract the toxic symptoms of the salicylates. In all cases 
when the salicylates are given in large doses one must care- 
fully watch for the development of drowsiness, acetone odor 
cf the breath and disturbances of the respiration. 

RICKETS. 

The associate symptoms of this affection are diagnostic ; 

1. During incubation, local sweatings (head and neck) 
and nocturnal fever preceding the period of bone-change. 

2. Deformation of the bones is marked by hyperesthesia 
or tenderness of the latter and pain on voluntary movement. 

3. Deformity of the thorax; changes in the epiphyseal 
junction of the ribs (rachitic rosary, characterized by a series 
of bead -like enlargements) ; pigeon-breast or chicken -breast. 

4. Deformity of the spine, exaggeration of the normal 
curves, scoliosis and lordosis, which are accentuated by the 
large size of the abdomen. 

5. Deformity of the head: oblong or square head, 
anterior fontanel open (closed in the norm about the i8th 
month); softened spots in the occiput (cranio -tabes), early 
decay of the teeth and retarded cerebral development. 

6. Deformity of the extremities : an increase in the size 
of the epiphyses (wrist, elbow, ankle, knee) which suggests 

143 



I 



S p n d y I the r a p y 

a joint (hence the popular expression "double-jointed") and 
bending of the long bones. 

Recovery may occur within a few months, the bones 
remaining thick and hard with firm and short muscles and 
partial disappearance of the deformities. 

SPINAL MENINGITIS. 

A chronic meningitis may be confounded with a tumor 
of the spinal cord or disease of the vertebral column and 
Horsley'* has seen a number of such cases which he has 
treated by laminectomy, opening the theca and washing it 
out with a mercurial solution. 

The cases occur most often in adults with syphilis or 
gonorrhea as possibly etiologic factors. 

In differential diagnosis the following points are of value : 
A tumor of the cord exhibits pain usually localized to one 
nerve-root, but in meningitis, the pains spread gradually to 
the front and back of the thigh and cause painful cramping 
and twitching of the muscles of the right leg. Other signs 
are tightness and numbness of the thigh and a progres- 
sive loss of power in the legs eventuating in a progressive 
paraplegia. 



144 



tbdominal Supporters 



I^^^^H^^^^^^^^^^g^^^^^^B^g^^^H 



CHAPTER V. 

GENERAL SPONDYLOTHERAPY. 

ABI>01CINAL SUPPORTERS — ACUPUNCTURE — COUNTERIRRITATION — 
ELECTROTHERAPY — ^EXERCISES — RE-EDUCATION OF CO-ORDINATED 
MOVEMENTS — SPINAL HYDRO-THERAPY — LUMBAR PUNCTURE — 
MASSAGE — PSyCHROTHERAPY — THERMOTHERAPY — VIBRATORY 
MASSAGE. 

ABDOMINAL SUPPORTERS. 

Reduced intra-abdominal tension conduces to a condition 
described by the author as intra-abdominal insufficiencyy and 
the latter contributes to a group of symptoms made up of 
backache and neurasthenia. 

Minor grades of insufficiency may be detected by the 
following signs, which the writer has described more fully 
elsewhere :'• first, auscultate the heart -tones, palpate the 
pulse, determine blood -pressure and define by percussion the 
borders of the heart and the upper border of the liver while 
the patient is standing. Next, direct an assistant standing 
behind the patient to firmly and forcibly lift the abdomen, 
exerting the pressure in a direction upward and inward. 
While the latter pressure is maintained, the foregoing methods 
of examination are again executed and if abdominal tension 
is reduced the following are noted : the heart -tones become 
stronger, the pulse fuller, the blood -pressure augmented from 
5 to 30 mm. and the percussion areas of the heart and liver 
become higher and more pronounced. 

The heart is prolapsed (cardioptosis) as well as the liver 
in diminished abdominal tension. 

The author has frequently noted a systolic aortic murmur 
when the abdomen was pendulous which disappeared during 

145 



Spondyloth 



P y 



L 



the time the alxlomen was raised by an assistant and re- 
appeared when the abdominal wall was dropped. This 
murmur is probably caused by traction on the aorta 
by a prolapsed heart, the result of an intra-abdominal 
insufficiency. 

Many of the local symptoms of reduced abdominal tension 
are at once relieved by raising the abdomen in the manner 
Suggested and if an abdominal support is employed, its value 
may be tested by noting the effects on the pulse, blood- 
pressure and position of the heart before and after its 
application. 

Those who object to mechanic supports will find in the 
method of Kellogg, an excellent means of strengthening the 
abdominal muscles and thus securing a natural increase of 
intra-abdominal tension; the electrodes of a sinusoidal cur- 
rent are placed on either side of the spine about four inches 
apart and just below the inferior angles of the scapula;. 
When the current is sufficiently strong, all the abdominal 
muscles will be thrown into vigorous contraction. 

ACUPUNCTURE. 

The author has already portrayed his conception of many 
diseases as expressed in the antagonism of muscles (page 
ii). This theory Is in accord with our percutaneous 
methods of treatment and refers with special cogency to 
spondylotherapy. In the foregoing pages the following fact 
has been elaborated, viz., that throughout the spinal region 
one may arouse definite reflexes and that every reflex has its 
counter-reflex. Thus our therapy by peripheral methods 
resolves itself into the following: either an abnormal 
reflex is inhibited or it may be antagonized by a counter- 
reflex. In a word, peripheral stimulation signifies irritation 
of centrifugal or centripetal nerves. In arousing the former 
146 




Acupuncture 

to activity we stimulate motor, secretory, trophic, inhibitory 
and thermic nerves, whereas stimulatic^n of the centripetal 
nerves predicates an action on the reflex-motor, reflex- 
secretory and reflex -inhibitory nerves * 

Liunbago (myalgia lumbalis), may be confounded with 
many reflex troubles and affections of the vertebral column. 
If the lumbar pains originate in the muscles alone, acupunc- 
ture, by its almost miraculous curative action, is diagnostic 

of lumbago. 

The method may be made painless by local anesthesia 
before ordinary sterilized bonnet -needles are forced into the 
painful points of the lumbar muscles and allowed to remain 
for about ten minutes. It may be necessary to repeat the 
manceuver. A number of smaller needles may be passed 
through the skin into the muscular tissue. The method is 
equally efficacious in the treatment of myalgias elsewhere 
and appears to be more successful in those who have bilateral 
pain. 

Sir James Grant supposes that the needles set free an 
excessive storage of electricity which has accumulated in the 
muscles. 

An intramuscular injection of morphine (i-6 grain) and- 
atropin (1-60 grain), or a few minims of chloroform, may also 
give immediate relief, but here it is difficult to differentiate 
the action of the medicament and the acupuncture. 

♦The excitability of certain nerve-centers is diminished by calling other centers into 
action. Franck, in the "Dictionnaire Encyclop^ique des Sciences M^icales" 
observes, that when one considers the normal functions of the nervous system, 
one finds that there exists a necessary equilibrium between the different parts 
of this system. This equilibrium may be destroyed by the abnormal pre- 
dominance of certain centers which seem to divert to their own advantage too 
great a proportion of the nervous activity; thus, the functions of the other 
centers appear to be disturbed. The ankle-clonus depends on an exaggerated 
excitability of the calf muscles. If now, I excite with the sinusoidal current 
the spinal segment (page 30) presiding over the muscles which antagonize 
the calf muscles, for a time, at least, the ankle-clonus can no longer be elicited. 
This method has been employed successfully by the author in overcoming 
spasms of definite groups of muscles. 

147 



S p n d 



loth 



r a p y 



COXJNTERIRRrrATlON. 



Counterirritants are valuable agents for the relief of pain 
if applied in correct situations. As we will notice in the 
subsequent chapter on pseudovisceral diseases, the pains 
usually experienced in the thoracic and abdominal walls are 




pains referred to the periphery, whereas the actual site of the 
lesion is alongside of the spine at the vertebral exits of the 
affected nerves. It is evident then, that if the cotmter- 
irritant is applied at the point where the pain is felt rather 
than at the site of the lesion, no result is achieved. It was 
the custom of Trousseau to trace a neuralgia along the course 
148 



Count 



rtrrttatton 



of a nerve to the spine from which it made its exit, at which 
site the painful point was blistered. 

In diseases of the hip, pain is felt in the knee, yet the 




counterirritant, to be effective, must be applied to the hip. 
Insomuch as counterirritants achieve their analgesic 
effects by influencing the distribution of blood in a part either 
reflexly through changes in the caliber of the vessels or by 
anemizing the morbid structures, leeching and cupping may, 
in many instances, achieve like effects. It may be necessary 
in some instances to accentuate counterirritation and for 
this purpose an escharotic or the actual cautery is used. 
149 



S P 



d 



I 



h 



a p y 



The obsen'ation of Head (page 58) sho\vs that the vis- 
cera and definite areas on the surface of the body receive their 
nerve-supply from the same segment of the spinal cord and 
that irritation of the one reacts favorably upon the other. 

It will be noted in the accompanying figures {40 and 41 ) 
from Brunton, that the areas established empirically for 
applying counted rritants to influence the viscera nearly 
correspond to the dermatomes of Head. 

Nothing in my experience equals freezing iyide psychro- 
therapy) for the purpose of counterirritation in spondylo- 
therapy and for this reason, I employ freezing to the exclusion 
of all other methods. 

Caniimrides is the usual vesicant employed, althoi 
many preparations on the market are useless. Before apply- 
ing cantharidal collodin or a plaster, wash with soap and 
water and then dry the skin thoroughly with alcohol and if a 
plaster is used, moisten it with a few drops of acetic acid. 
Vesication occurs in about eight hours. At the end of that 
time, carefully remove the plaster to avoid rupturing the 
bleb and puncture the latter at its most dependent part with 
an antiseptic needle and dress with dry absorbent cotton. 
After the latter fashion the skin rapidly forms under the 
blister. If the latter is broken, sprinkle the surface with 
ortho/orm, which renders the healing painless. 

Cantharides is readily absorbed from the skin and toxic 
symptoms (strangury, priapism and nephritis) may follow, 
hence blistering must be achieved with other drugs. 

Methyl iodid has no unpleasant action on the urinary 
organs. About 1 5 to 30 drops of the liquid is poured on a 
piece of blotting paper which has been cut to the desi: 
size and then fastened to the cleansed skin by adhesii 
plaster. Blisters appear in from 3 to 18 hours. 

A blister may be produced in several minutes hy sal 
ISO 



ply^ 



-£ lee tro therapy 

ing a piece of lint with chloroform and after its application 
covering it with oiled-silk or a watch-glass. 

Equal parts of lard and ammonia will blister in about 
five minutes. 

ELECTROTHERAPY.* 

It is yet customary to regard the results obtained from 
electric treatment as dependent on suggestion. Moebius 
tells us that four-fifths of all electric cures are dependent on 
mental influence. Even Beard, who, in his time, was one 
of the leaders in electrotherapeutics, is quoted by Kellogg 
as saying : "If you expect to get definite results from electrical 
applications, you must be sure that your patient has faith, 
otherwise the application will do him no good.'' 

Electrotherapy is now founded on a scientific and, what 
is more important, a utilitarian basis. All currents do not 
show the same physiologic and therapeutic effects any more 
than do the various alkaloids derived from opium, although 
the same plant is the conmion source of all. The discovery 
of the SINUSOIDAL CURRENT is accredited to D'Arsonval, 
although Kellogg's description of the current in 1888, pre- 
ceded the publication of the former. 

The sinusoidal current does not produce the unpleasant 
and painful effects of the Faradic current and is decidedly 
more effective for the average therapeutic purpose than is 
the Galvanic current. The Faradic current is alternating 
in character in which the break in the direction of the current 
occurs at the maximum point of intensity. The Galvanic 
current is continuous and any change in the direction or in 
the interruption of the current is a sudden break associated 
with a pamful shock. 

*Oiily the sinusoidal current will be described, as it is used by the author almost 
exclusively in the diagnosis and treatment of spinal diseases. 

151 



S p n d y I 



t h 



P y 



The preceding conditions with the sinusoidal current do 
not exist. It is probable that the rapidity of alternations is 
so great that the sensory nerves fail to appreciate the im- 
pressions of such high frequency. The current gradually 
rises from the base line, zero, to the maximum, then equally 
graduaUy returns to zero, then likewise rises to the maximum 
in the opposite direction, and returning to zero repeats the 
rhythm at the rate of many thousand alternations per minute 



(Fig. 42). 




FiC. 4J. — A inie sine curve Irom which the sinusoidal current obtains iu 
name. The length of (he sine being from points i to 1, which is one complete 
cycle and two complete alternations. In what is called the 60 cycle current, which 
goes through this change sixty times per second, this distance [rom I to 1 repre- 
sents one-sixtieth of a second and in the 125 cycle variety, 1-115 of «t second. 
These currents are sometimes spoken ai as having 7,100 and 15,000 respectively' 
alternations per minute, since there are, of course, two allcrnaljons (one each 
way) in each cycle and 60 seconds in a minute. The distance ot this curve above 
or below the horizontal neutral tine represents at each instant the potential or 
degree of polarity at thai point, the points above the line being positive and ' 
below negative, and this degree uE polarity determines the strength of the Cl 
ax that instant and the direction of its ftow. 



Many of the sinusoidal apparatuses on the market are 
such in name only and do not achieve the results cited in 
this work. 

With the original Kenelly machine, one could obtain a 
frequency up to 150,000 alternations per minute. The 
latter machine is, however, too expensive for general use and 
with less costly apparatus equally efficient results can be 
attained. 

The author's (Fig. 43 ) apparatus is simple in constructi( 



% 






current. ^^^^^H 



d 



t h 



a p y 



of the current obtained is very much restricted. The Galvanic 
current may also be obtained from the same apparatus. 

Doctor J. H. Kellogg's sinusoidal apparatus* (Fig. 44) 
embodies Kellogg's discoveries and is a very efficient appara- 
tus for obtaining sinusoidal effects. It is provided with a 
finely graduated rheostat, by means of which the powerful 







Fig, 44. — Sinusoidal apparatua of Di. J, H, K.ellugg, 

currents generated may be reduced to the smallest require- 
ment. It consists essentially of a specially constructed! 
magneto-generator operated with an electric motor. A. 
slowly alternating current designated as SS (slow sinusoidal), 
is usually employed for muscular effects, and the rapidly 
alternated current RS (rapid sinusoidal), is used to induce 
powerful tonic contractions and to secure analgesic action 
other nerve-effects. 

Another efficient apparatus (Fig. 45 ) for sinusoidal 
purposes is the outfit made by the Victor Electric Company 
of Chicago. In the multiplex outfit of the latter company 
one can adequately control the length of the sine wave 
the voltage as well. The apparatus can be attached to an] 

*Madc by the Modern Medicine Company, Baltle Creek, Michigan. 
154 



I 

ice 

1.1 ^ 




E I 



p y 



electric -light socket and it is calculated for the direct current. 
It is also supplied for connection to the alternating current, 
but when employed in this way its value is very much 
restricted. 

When the Victor apparatus is employed for eliciting the 
vertebral reflexes, the author suggests only the employment 
of the rapid sinusoidal current. 




Fic. 4s. — Sinusoidal apparatus made by the Victor Elearic Company. 



DIAGNOSTIC AND THERAPEUTIC APPLICATION 
OF THE SINUSOIDAL CURRENT. 

This subject will be discussed in detail in special chapters 
devoted to visceral diseases. One of the most important 
properties possessed by this current by its cutaneous appli- 
cation alone, is the powerful and demonstrable action on the 
internal organs. Thus, with one electrode at an indifferent 
point (the author prefers the sacral region), and the other 
over the regions of the various organs, visceral reflexes may 
155 



be elicited. If both electrodes are applied to the abdomen 
it reduces intra-abdominal congestion. 

By aid of this current, as will be demonstrated later, 
toxic intestinal and hepatic products are brought to resorption 
and excreted in the urine. 

The various vertebral reflexes (page 7) can be elicited 
by this current, but for therapeutic purposes, concussion 
(page 17s) often exceeds it in value. 

The current has a specific action in hyperesthetic con- 
ditions whether superficial or deep-seated, and is of all 




Fig. 46. — Intetrupling cletlrodcs. 

currents the most available for inducing analgesic effects. 

It is very often the most efficient current for developing 
weakened muscles and not infrequently it wiU provoke 
muscular contractions in degenerative lesions when Faradism 
produces no response. 

In applying this current for diagnostic and even for 
therapeutic purposes the moistened indifferent pad (usually 
large) is placed over the sacrum, whereas the interrupting 
electrode (Fig. 46), which permits one to close and open 
the circuit, is placed over specific regions. 

To induce muscular contractions it is not necessary, as in 

the use of other currents, to find the motor points (points of 

greatest excitability). To obtain the maximum contraction 

of the muscles of the back, the latter must be relaxed. 

156 



E I 



h 



p y 



To excite the muscles of the back for diagnostic or develop- 
mental purposes strong currents must be used. Referring 
to Fig. 47, the effects of a strong sinusoidal current are noted 




Fic. 47. — Muscles of the back showing Triangle of Petit (shaded triangular 
area). The Ira/taius retracts the scapula and braces back the shoulder; when 
the head is filed, the upper part of the muscle will elevate the point of the shoulder 
(electromotor point, E.M.P.. A], whereas the lower iibres depress the scapula 
(E.M.P., B); with fixed shoulders, action of one trapezius vrill draw the head to 
the conrsponding side (E.M.P., C). The laliiHmus dorii when the arms are 
fixed raise the lower ribs and assist in forcible inspiration (E.M.P., D). Application 
of the electrode al any of the points marked E, E, E, will accentuate the lordosis 
in the lumbar region and, at F, on the right side, scoliosis is produced lo the left 
side, and, at a corrcBponding point on the left side, scoliosis to the right side. By 
marking the tips of the spinous processes or by noting the spinal furrow, the scoliotic 
changes are best observed. G, electromotor point which causes an approximation 
<rf the scapula lo the spine. 



when one pole is applied over the sacrum and the interrupting 

electrode is placed at various points indicated by circles. 

The effects of this current can be more easily demonstrated 

157 



if ihe spinous processes are marked with a pencil, thus indi- 
cating any deviation of the vertebral column. Changes in 
the curvature of the spine are naturally less evident in adults 
than in children. 

This current is specially indicated when the development 
and strengthening of the spinal muscles are the objects in 
view. Here the electrodes must be placed at corresponding 
points on either side of the spine so that the muscles on one 
side should not exceed in development or strength the muscles 
on the other side. By inducing the central reflexes (page 
ii), a symmetrical development is easily achieved. 

A backache is very frequently a weak back ; the muscular 
tire graduating into pain and here the remedy is muscular 
development. 

It is difficult to devise any exercises which will bring into 
action the thirtynane muscles of the back which are sub- 
divided into five layers. 

Not infrequently, the so-called uric-acid diathesis is a 
localized intoxication ; the unused muscles favoring the pre- 
cipitation of uric-acid or other products of defective meta- 
bolism and creating what is popularly called "stiff-back." 
To destroy such products, it is necessar>' to bring a greater 
supply of blood to the parts, for more circulating blood means 
more oxygen and more o.xygen means better nutrition. 
Sinusoidal ization of the muscles of the back is more efficient 
than any exercises. The author has investigated the output 
of urea before and after sinusoidalization of the muscles of 
the back in many cases of backache and noted the pertinent 
fact that, as a rule, there was an augmented excretion of urea 
after sinusoidalization. Voit has shown that work does not 
increase the elimination of nitrogen by the urine, hence the 
increased output in my cases was due to the removal of urea 
stored up in the muscles. 

158 



E 



X 



It is evident to the reader that in the event muscular 
rigidity is present, muscular contraction is less readily elicited 
by the current than when the muscles are relaxed, hence in 
this respect, the current subserves a diagnostic use. 

EXERCISES. 

About one-half of the body-weight is dependent on the 
muscular system which, even in a state of rest, holds about 
one-quarter of the total quantity of blood When the muscles 
are in activity the amount of blood which they hold is very 
much augmented. 

Muscular exercises subserve the following objects : 

1. They increase the frequency and amplitude of the 

respiratory movements. 

2. By increasing pulmonary capacity they aid the work 

of the right heart. 

3. By determining an increased quantity of blood to 

the muscles* certain congested areas are depleted.f 

4. Waste-products are increased in the blood and there 

is augmented excretory activity of the kidneys, 
skin and lungs. 

In prescribing exercises, one must never forget their bane- 
ful effects on the nervous system when carried to excess. 

When a muscle is fatigued by voluntary contraction, it 
involves not only the muscle but the nervous system, and the 
latter to a larger degree than the former. It is erroneous to 
suppose that a healthy nervous system can be acquired by 
vigorous muscular exercises. The latter always means an 
expenditure of nerve -force which may, or may not, be beyond 

^Oliver has shown that the relative quantity of the corpuscles is increased in the 

blood of an exercised limb. 
fThe same author has demonstrated that while, after a period of rest, a relatively 

large amount of blood can be expressed from the abdomen into the systemic 

vessels, no such result can be attained by abdominal compression after 

exercises. 

159 



S p ondylotherapy 

the capacity of the individual. Many nervous wrecks are 
recruited from this fallacious argument. 

Spinal exercises achieve the following objects : 

1. Increased flexibility of the spine. 

2. Strengthening the muscles which hold the trunk 

erect. 

3. Combating a faulty attitude. 

Supports and plaster-jackets in the treatment of oirva- 
tures are only indicated in acute inflammatory affections of 
the bone. Otherwise they conduce to ankylosis in a deformed 
position with muscular atrophy from disuse. 

Impaired mobility of the spine is frequently the cause of 
distressing backaches, sciaticas and other affections. Here 
passive movements of the spine are often curative. The 
patient sits on the bed and the physician can repeatedly force 
the body forward or he can execute any degree of traction 
on the arms. 

Exercises for the muscles of the back are most often 
prescribed in the treatment of round shotUders and lateral 
curvature. 

ROUND SHOULDERS.* 

This condition is more frequently encountered in girk 
than in boys, owing to the fact that in the adjustment of 
clothes there is a drag upon the shoulders equal to several 
pounds on either side. Here, as Goldthwait suggests, the 
weight must be removed from the outer part to the inner or 
rigid part of the shoulder at the base of the neck. The 
patient should be taught to assume a correct position, chest- 
deformities must be corrected by breathing, gymnastics, and 
the following exercises recommended by Lovett are indicated ; 

*Vide page 96. 

160 



E xercises 

1. The patient h^ngs from a bar by the arms. 

2. In the recumbent position, with a hard roll under 

the scapulae, the arms are extended and stretched 
and pulled above the head upwards and back- 
wards by an assistant. 

3. The patient sits on a stool with the hands behind the 

head and the elbows squared; during the time the 
elbows are pulled backwards, the knee of the 
manipulator presses forward against the spine on 
a level with the shoulders. 

LATERAL CURVATURE. 

Here muscular exercises constitute the essential part of 
the treatment. At least one hour daily must be devoted to 
their execution, and as Robert Jones suggests, the arms 
should always be moved by direct muscular effort and not 
-allowed to swing. 

Ridlon*' employs the following exercises : 

1. The patient lies upon her back upon a table of con- 

venient height, width and length. The Swedish 
table known as the plinth is perhaps the most con- 
venient. With her arms at the sides of her body, 
and the palms upwards, she breathes slowly and 
deeply ten times. In patients who present a pro- 
jection of the ribs below the breast, it is of advan- 
tage for the surgeon to make pressure downwards 
with his hands upon these projecting ribs as the 
patient takes a full breath. 

2, The patient grasps a bar of steel shafting 3-4 ft. in 

length and 10-20 lbs. in weight. With the elbows 
straight, she swings this from the thighs forwards 
and upwards above the head until the bar reaches 
the level of the table. From here she swings it 
downwards again to the thighs, and this is repeat- 
ed ten times. 

161 



S p n d y I t h e r a p y 

3. The arms are then stretched directjy outwards from 

the sides of the body, and in this position, as in (i), 
she breathes deeply ten times while the projecting 
ribs are held down by the surgeon. 

4. Again, the iron bar is swung from the thighs to the 

table above the head and back ten times. 

5. Then the arms are stretched upwards by the side of 

the head to the fullest reach, care being taken that 
the lower shoulder is raised as far as the other. 
The arms are held in this position, and the patient 
breathes deeply ten times, the ribs again being 
held down. 

6. Then an iron bar of the same length, but double the 

weight of the former, is placed in the patient's 
hands as she lies upon her back, and she raises it 
direcdy upwards from the chest, fully straighten- 
ing the arms, and repeats the exercise ten times. 

7. Still lying on the back, with the knee held straight 

and rigid and the foot extended, the patient circles 
the limb from the hip-joint, making as large a 
circle as possible with the foot ten times. Then 
the other limb is circled in the opposite direction 
ten times. 

8. Still lying on her back with hands grasping the top 

of the table, both limbs are lifted, while the knees 
are held straight and the feet extended upwards 
to the fullest point, if possible to the vertical 
position, and repeated five times. 

9. The patient then turns on her face, is pushed out so 

that the body extends beyond the end of the table 
by the surgeon, and she, holding the head and 
shoulders as high as possible, makes with her 
arms the motion of swimming, the forward stroke 
of which should be particularly vigorous. In this 
position ten strokes are taken. 

162 



X 



10. The patient is then pulled back upon the table, and 

lying face downward with the knee straight and 
the foot extended, she circles first one leg and 
then the other, making the largest possible circle 
with the foot, ten times. 

11. The patient is again pushed out with the body 

beyond the end of the table, and with the arms in 
the key-note position, she bends the body down- 
wards and raises it upwards as far as possible. 
This is repeated five times. 
The key-note position consists of such a position of the 
arms as places the back in the straightest line. 
For an ordinary dorsal curvature with a convexity 
to the right, the key-note position consists of 
pushing the left arm as far as possible up beside 
the head and holding it there close to the ear, 
while the right arm is stretched directiy outwards 
with the palm turned upwards; but the key-note 
position must be determined for each particular 
case. 

12. With the patient again pulled back and lying com- 

fortably upon the table, she takes a 5-lb. dumb- 
bell in each hand, and swings them outwards and 
upwards, that is, backwards, as far as possible, 
ten times. 

13. The patient, still lying on her face on the table, 

places her arm in the key-note position; then as 
she counts aloud one, two, the legs are held down, 
she raises the head and shoulders upwards and 
backwards as far as possible; then, counting 
three, foi|r, she bends the head and shoulders as 
far as possible towards the convexity of the curva- 
ture; then counting five, six, she twists the head 
and shoulders around towards the side of the 
convexity, as if in an efiFort to look over the 
shoulder; then, counting seven, eight, she swings 
and turns back into the straight position from 
which she started, and this exercise is repeated 
five times. 

163 



S p n d y I t h e r a p y 

14. The patient then sits astride the narrow end of the 

table, while the surgeon sits astride the table 
behind her, steadying her hips with his knees. 
Then, with arms in the key-note position and the 
spine as straight as possible, she bends forward 
from the hips freely, and then backwards against 
the resistance exerted by the hands of the surgeon. 
This is repeated five times. 

15. Then, with the arms stretched out from the side, 

she twists the body freely towards the side of the 
concavity; then she twists backwards towards the 
side of the convexity against the resistance afforded 
by the hands of the surgeon, one hand resting 
against the ribs forming the convexity of the cur- 
vature at the back and the other against the ribs 
that are prominent below the breast in front. This 
exercise is repeated five times. 

16. The patient is then bent backwards and to the side 

of the convexity of the curvature over the knee of 
the surgeon, so that her waist rests through the 
bulging ribs across his knee, while the shoulder 
on that side is twisted still further backward. In 
other words, the position assumed is the one, both 
as to flexion and rotation, which most nearly 
corrects or over-corrects the spinal deformity. 
Lying lax in this position, the patient breathes 
deeply ten times. 

In the early months of treatment greater improvement 
will be gained if the patient exercises in the prone position. 
Patients with lateral curvature are able.to lie with the spine 
straighter than when they sit or stand, and the success of the 
treatment depends greatly upon making muscular effort 
while the spine is at its best. 

Klapp's ^^ Creeping Exercises^'* are not only useful in 
scoliosis but are equally efficient in expanding the chest by 
mobilizing the thoracic vertebrae. 

164 



Re-Education of Movements 

The patient kneek, the thighs perpendicular, the elbows 
bent so that the arms imitate the bow-leg position of the 
dachshund while the head is bent far back. The pelvis is 
thus above the shoulders and the thoracic portion of the spine 
is in lordosis; this position must be maintained during the 
creeping. The arm is advanced and stretched before the 
hand touches the floor. This hand then turns and the elbow 
is bent as the trunk is advanced until the upper arm forms a 
right angle with the trunk. The arm thus forms the axis 
over which the thoracic vertebrae are levered by the drawing 
forward of the other arm, the scapula of the supporting arm 
forming the fulcrum of the lever. This exercise loosens up 
the thoracic vertebrae and spreads the ribs apart, and corrects 
torsion of the spine if present. The thorax expands more, 
the more correctly the lordosis of the thoracic vertebrae is 
localized during the sideward bend. 

RE-EDUCATION OF CO-ORDINATED MOVEMENTS. 

In locomotor aUiocia, co-ordination exercises are of great 
value in regaining control of the voluntary movements which 
have been lost. The exercises in question exert no effect on 
the lesions and the best results are attained when the motor 
tract is intact. It is not necessary to employ the apparatus 
of Fraenkel to achieve results; in fact, good results are 
equally achieved without apparatus.*^ 

In executing the exercises the following rules must be 
observed: 

I. One must begin with simple exercises; first with the 
eyes open and later with the eyes closed. Each 
movement must be executed with precision. 

3. Fatigue must be avoided, hence the exercises should 
be taken in the recumbent and later in the sitting 
and erect postures. Fatigue may be avoided by 

165 



Spondylotherapy 

— — ^— — — — — — — ^— — — — — — — — . 

counting the pulse which, when increased in fre- 
quency beyond the norm, indicates that the 
exercises must be temporarily suspended. At 
first the stances should not last longer than about 
ten minutes and later the entire exercises, includ- 
ing resting periods (to enable the pulse to become 
normal) should not exceed thirty minutes. 

3. A trained assistant for supervising the exercises is 
equally as important as the patient's persever- 
ance. 

Respecting the nature of the exercises, each ph)rsician will 
suggest his own methods. After the patient succeeds in exe- 
cuting simple movements with his ataxic extremities, then 
walking exercises like the following are indicated : 

1. Line- walking in a straight line. 

2. Walking at a mark which is placed on a wall at a 

limited distance. 

3. Obstacle- walking. By placing books on their long 

edges about 20 inches apart and then directing the 
patient to walk over them. 

4. Stair-walking. Ascending and descending steps. 

SPINAL -HYDROTHERAPY. 

The spinal-coil has replaced the Chapman bags. The 
former consists of thin rubber tubes through which a con- 
tinuous current of water of any desired temperature is per- 
mitted to flow and is applied to the spine (never directly 
upon the skin) upon a thin moist compress. The bags of 
Chapman consist of the usual rubber bags (long and narrow) 
which can be filled with ice or water of any desired tempera- 
ture and are placed upon the vertebral column. Cold 
applied to the cervical spinal -region (used in asthma and 
cardiac irritability) has a primary stimulating action suc- 
ceeded by sedation. Cold applied to the lumbar spine, 

166 



Lumbar Puncture 

determines an increased flow of blood toward the lower 
extremities and the pelvic organs. Heat applied to the 
lumbar spine is said to diminish the flow of blood to the 
pelvic organs hence it is indicated in excessive menstruation. 
Cold applied to the entire spinal column reduces general 
reflex irritability and is employed in spinal neurasthenia. 

In the rational employment of hydrotherapy, heat or cold 
water must be applied by means of a douche to definite 
vertebrae to elicit specific reflexes. The author, however, 
regards electricity and vibra-massage as more convenient 
methods insomuch as the object to be attained irrespective 
of the method employed is to evoke definite reflexes. Win- 
temitz suggests the use of cold water poured over the back 
of the neck for relieving nasal congestion. He ascribes the 
result to action on the vaso-motor center. Elsewhere (page 
284), the author directs attention to a more certain and 
permanent method for achieving the same object. 

LUMBAR PUNCTURE. 

Lumbar puncture is usually made just below the tip of 
the fourth lumbar spine (fourth interlaminal space) with a 
sterilized needle about three inches in length attached to a 
siyringe or with a small trocar and canula. 

If a horizontal line is drawn across the back on a level 
with the highest points of the iliac crests it will cross the spine 
at the level of the tip of the 4th lumbar spine. 

The patient should lie on the left side with knees drawn 
up and the trunk bent forward. The skin at the site of the 
puncture may be frozen. The physician places his finger 
on the tip of the 4th lumbar spine and introduces the needle 
half an inch below and to. the right of the 4th lumbar spine, 
and directs it horizontally forwards and a little inwards until 
the arachnoidal space is reached. When the syringe is 

167 



Spondylotherapy 

detached, the fluid escapes in drops and the amount per- 
mitted to escape at a single stance should not, as a rule, 
exceed 5 cc. 

Lumbar puncture is indicated for the relief of headaches 
of various origin due to augmented intracranial pressure. 
Thus, the pains secondary to herpes zoster have been relieved 
by the withdrawal of 20 cc. of fluid and it was therefore 
assumed that hypertension of the fluid existed. 

Vertigo and tinnitus dependent on increased pressure of 
fluid in the internal ear are likewise relieved. 

MASSAGE. 

The pressure exerted by massage influences all the 
tissues within its reach. It increases the power of endurance 
and abolishes fatigue. Experiments on frogs show that, 
after the muscles have been exhausted, their loss of vigor is 
soon restored by massage, whereas rest without massage has 
no effect. 

Massage increases the flow of blood and lymph. Brunton 
has shown that the blood passes three times more rapidly 
through a part while it is being mass^ed than when it is not. 
In many cases there is an increase in the number of red 
corpuscles and in the hemoglobin. Upon the nervous 
system, massage, if properly done, has a sedative effect. 

Therapeutically, massage accomplishes the following : 

1. It assists the peripheral circulation and lessens the 

work of the heart. 

2. In tissues accessible to manipulation it hastens the 

resorption of exudations and separates adhesions 
in joints and tendon-sheaths. 

3. It augments the oxidizing powers of the blood, thus 

modifying disturbances in its composition. 

168 



M a 5 s a g e 

4. By stimulating the sympathetic nervous system it 

promotes secretions and various reflexes, and thus 
gives relief in functional derangements. 

5. By augmenting the flow of blood in the muscles it 

diminishes congestion of the viscera. 

6. Wright has demonstrated that the efifect of massage 

on an infected joint, by discharging a number of 
bacteria into the circulating blood, is to raise the 
opsonic index, after temporarily lowering it in 
in the first place. 

In the manipulation of joints any elevation of temperature 
signifies extreme caution in manipulation, in fact, any in- 
creased temperature is a contra-indication for the employ- 
ment of massage in affections of the joint. When it is a 
question between a functional and an organic joint-ksion 
the experience of the author shows that if fever follows 
passive movements of the joint it suggests an infectious lesion 
and the leucocyte count, as a rule, is increased. 

Dowse observes that ten minutes massage of the spine will 
increase the volume of the pulse and the temperature gen- 
erally more than one hour's work at the body as a whole, the 
spine being omitted. 

Fig. 48 demonstrates a series of visceral reflexes excited 
by deep pressure at the vertebral exits of the various spinal 
nerves. The foregoing figure has been elaborated after a 
series of very careful clinical observations by the author. 
Firm pressure is usually made with the thumb of one hand 
and it is indeed remarkable how, in many instances, the 
symptoms may be relieved and even cured by such deep and 
firm pressure over definite regions. It is evident to the 
reader that if such pressure is executed promiscuously, 
counter-reflexes are evoked which nullify the reflexes sought. 
In fact, the symptoms by such promiscuous manipulation may 

169 



S p 



t h 



p y 



be accentuated. One may observe quite frequently that when 
pain due to a spinal neuralgia is associated with a point of 
vertebral tenderness, temporary inhibition of the pain may 
be achieved by deep pressure on the sensitive vertebral area 
and, in this respwct, pressure may accomplish in an emergency 
almost as much as psychrotherapy. If the pains arc of 
visceral origin and are associated with a point of vertebral 
tenderness, pressure upon the latter point is decidedly less 



HIGHT 



contTactioi 
Ti^ht lun; 




LEFT 

Contraction 

left lungr. 

»ntractio 
ana aort 
.Cardiac inhibition. 

Dilatation left 
lung, 

pilatation of 
Tntestme and 
.stomach. 

Contraction of stom 
ach, intestine, and 
spleen. 



. Car^iAC 
inhibition 

Dilatation 
ri sht lun; 

pijatation ■ 
Tnteatine & 
enlargement 
of liver. - 
Contraction" 
of intes- 
tine ana 
liver. 

Fig, 4S. — Visceral reflexes elicited by firm pressure at rfefmi 

effective in relieving the pains. When It is necessary to make " 
more forcible compression at the vertebral exits of the sen- 
sitive nerves the author employs his vibro-suppressor (Fig. 
32 ) with a smaller pelote or he makes pressure with one end 
of the rubber of a pleximeter. The latter is shown in Fig. 2. 
Assuming that a patient has a neuralgia of the cervico- 
occipital nerves, one seeks for a sensitive point at the verte- 
bral exits of the cervical nerves usually on one side of the 
spine. As a rule, muscular spasm of the cer\'ical muscles 
170 



Points of Election 

b associated with such a vertebral area of tenderness. 
Hence, before pressure is exerted by the thumb over the area 
of sensitiveness, the head is thrown backwards so as to relax 
the muscles. As a rule, pressure is primarily painful, but it 
soon yields to continued pressure and the neuralgic pains 
cease at once. A repetition of such manipulation may be 
necessary on successive days before the pain is permanently 
relieved. 

The author has observed that pressure exerted after the 
foregoing method at the vertebral exit of a spinal nerve has 
usually only a slight eflFect on the cutaneous sensitiveness in 
the normal subject. If, however, the nerve is the site of a 
neuralgia, a decided eflFect can be observed on a given area 
of skin-tenderness. 

Many osteopaths exercise great discretion in their man- 
ipulations insomuch as they do not massage the parts aflFected, 
but exert pressure upon the exits of the spinal nerves which 
are correlated to the parts involved. Thus the parts impli- 
cated are merely placed at rest and not manipulated until 
the acute symptoms have subsided. 

The POINT OF ELECTION for pressure at the vertebral exits 
of the spinal nerves may be determined (if spasm or tender- 
ness is absent) by noting the site of spasm of the spinal 
musculature (page 47), when an organ or tissue peripheral 
to the region of the spine is manipulated or by the develop- 
ment of an area of vertebral tenderness* (page 71) after 
such manipulation. 

The conductivity of a nerve may be temporarily diminished 

*The area of vertebral tenderness is often more conspicuous on the side of the 
spinal column opposite to the source of cutaneous irritation and this fact must 
be taken into consideration in employing our therapeutic manoeuvers. The 
foregoing observation aids in solving the dubitable question concerning the 
propagation through the spinal cord of sensory impressions received by the 
skin ; in all probaLtlity, the impressions after entering by the posterior horn 
ascend on the same side, whereas other impressions cross to the opposite side. 

171 



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n d y I 



t h 



r a p y 



or abolished by external pressure (familiar example of the 
limbs "going to sleep") without annihilating its physical 
integrity. 

As remarked on a previous page (page 72), some writers 
associate the areas of paravertebral tenderness with the 
vaso-motor subcenters in the cord and claim that when the 
areas have become chronic, the paravertebral tissues are 
infiltrated and thickened. Here deep massage of the 
affected areas is indicated. 

PSVCHROTHERAPY. 

In the treatment of locali/xd areas of vertebral tenderness, 
nothing in the experience of the author exceeds cold as a 
remedial measure. To attain any result, however, the skin 
overlying the area of tenderness must be distinctly whitened 
and frozen and this condition must be maintained for one or 
two minutes. Very often a single application suffices for the 
cure of a neuralgic affection but, in other instances, the 
process must be repeated on several successive days. 

The author has never noted any bad effects from such 
radical freezing as a remedial measure. The hjperemia 
resulting may be assuaged by a simple dressing of zinc oint- 
ment on lint fixed to the part with adhesive plaster. Among 
the agents used for freezing are rhigolene and etker which are 
used in an atomizer and directed on the part to be frozen. 

Recently the author has been unable to obtain rhigolene, 
hence ether was employed in its place. Other freezing agents 
are elhyl chlorid Bengti'e and Keline, which are sold in glass 
tubes and by holding one of the latter in the hand a fine jet 
is projected on the area to be frozen. The nozzle is held 
from 6 to 8 inches from the skin. The latter first becomes 
pink, then a deep red and finally white, like parchment. 
The latter degree must be reached and maintained for se^'era 
minutes. 

172 




Psych r t h e r a p y 

The author has also used for freezing a preparation of 
benzine (Distilled between 35 and 45 degrees C), which is a 
cheap and eflBcient fluid for freezing. The odor of the latter, 
like ether, may be objectionable, but this may be corrected 
by the addition of some essential oil to either preparation. 

Many preparations of ether on the market are quite in- 
efficient, but if ethyl chlorid is first used until the skin is 
whitened, almost any preparation of ether will maintain the 
freezing ad libitum. Ethyl chlorid or K616ne is too expen- 
sive if used extensively, hence, in the absence of a reliable 
ether preparation for freezing, first freeze with ethyl chlorid 
or K616ne and then maintain freezing with practically any 
preparation of ether. 

The foregoing liquids are inflammable and should not be 
used near a light. 

In an emergency, a piece of ice sprinkled with fine salt 
and held against the skin by means of a towel will freeze the 
part. 

The author has had no personal experience with either 
liquid air or carbonic acid snow for freezing purposes and for 
information on this subject the reader is referred elsewhere.*' 

In intractable pains due to lesions at the vertebral exits 
of the nerves, the author has had recourse to what he calls 
reinforced freezing. It consists of injecting sterilized water 
beneath the skin over the part to be frozen or directly into the 
tissue until an appreciable bulging is produced. If the 
freezing solution is now directed on the protuberant part, a 
lump of ice is formed under the skin or in the tissues. 
Respecting the rationale of congelation the author directs the 
reader elsewhere*' to his investigations on the subject. Yide 
page 187, concerning the use of freezing in spinal neuralgias.* 

^Vide page 367, concerning the employment of concussion for the relief of pain. • 

173 



ondyloth e r a p y 



THERMOTHE R-VP Y. 



This refers to heat as a therapeutic agent. Media having 
a temperature above that of the body are referred to as hot 




for inllucncEng the visci 



and as very hot, when the temperature exceeds 104 degrees 1 
(40 degrees C). 



Vibratory Massage 

Respecting the ph)rsiologic eflFects of heat, it suffices to 
say, that a prolonged application of a high temperature is 
primarily an excitant, and secondarily, a depressant ; a brief 
application, however, is strongly excitant and the depressing 
effects, if any, are imperceptible. 

The viscera are influenced reflexly through cutaneous 
areas (Fig. 49) which have been definitely established and 
are of great clinical importance. As a rule, the cutaneous 
reflex areas overlie the individual viscera, but in the author's 
experience, the most pronounced effects are achieved by the 
application of heat (very hot water in small rubber bags) 
over the different vertebral regions; a brief application to 
secure stimulating effects and a prolonged application to 
achieve sedative action. 

Von Bemd, by means of an apparatus which consists of a 
transformer, a high frequency current is obtained from the 
usual electric supply and which, when passed through the 
tissues, subjects the latter to any degree of heat which can 
be modified at will. With this apparatus the gonococci in 
an infected joint have been killed within one-half hour. 

Electro-thermal pads of any size, attachable to an 
electric light socket, are now purchasable and supply a 
uniform source of heat. They are also made to contain 
material used for cataplasms, thus obviating the necessity 
of changing the latter to secure a constant supply of warmth.* 

VIBRATORY MASSAGE (SISMOTHERAPY). 

Vibra-massage or mechanic vibration has achieved some 
distinction as a remedial measure, but owing to its indis- 
criminate application without regard to physiologic principles, 
most of the results attained by its use must be attributed to 

*Made by the F. R. Whittlesey Co., 591 66th Street, Oakland, Gal. 

175 



suggestion. The author only seeks to discuss vi bra -massage 
with reference to its spinal application, and it will be evident 
to the reader if he has given careful consideration to the 
vertebral reflexes (page 7), that the manipulation of 
definite vertebrte corresponds with the elicitation of definite 
reflexes but, if the vertebrte are promiscuously handled, 
counter-reflexes are evoked, which may often accentuate the 
reflexes in action and thus intensify the co-existing symptoms. 

The foregoing sentence has been quoted several times 
throughout this book, but it is deser\'ing of repetition. 

In the therapeutic elicitation of the vertebral reflexes, the 
only kind of vibratory apparatus which is effective is one 
giving the percussion stroke. All other motions, such as 
oscillations, shaking and friction, interfere with the results. 
In other words, it is concussion and not vibration which is 
etTectivc. 

Vibration is milder and of higher frequency than per- 
cussion. 

The author has tested verj' many devices for vibra- 
massage and has been disappointed with the results. Thus 
there are many instruments which concuss, but in so doing, 
they also produce considerable friction, which is undesirable 
in prolonged stances with the apparatus. 

When the author first employed vi bra.- massage with in- 
adequate apparatus, the friction provoked in association 
with concussion, resulted in severe wounds over the spinous 
processes. Such accidents no longer occur in the author's 
experience, although the spinous processes may become 
tender owing to a mechanic periostitis which is of little or no 
consequence. 

With an apparatus which does not cause friction, the 
concussors (Fig. 50) may be applied directly to the spinous 
process or processes and the application can be prolonged 
176 



fur sevL-ral minutes at a lime. In the event friction attends 
the use of the apparatus, one must interpose some medium 
between the concussor and the spinous process. Here a 
strip of linoleum is efficient and the treatment must be inter- 
rupted at once if the patient complains of a burning sen- 
sation.* The author's apparatus (Fig. 50) is essentially a 




i 



Fie. 50, — The author's pneumatic hammer wilh 

pneumatic hammer giving a stroke of ri inches and operated 
by compressed air. The force of the concussion -blow may 
be regulated by a stop-cock or by the pressure of the con- 
cussor on the spinous process. To start the action of the 
hammer it is often necessary to place the finger on the suction 
opening and then suddenly release it or strike the concussor 
forcibly with the hand. The absence of latch pins, springs 
or plugs avoids any waste of air and insures a steady working 



[ 8 Iftyer of rubber (i cm. in thickness) covers the surtarc of the cor 
heal is gcnermted and there is no neceasily for interposing a mediuj 
the skin and the o 



Spondylotherapy 

hammer. No vibration is transmitted to the operator's hand. 
Although quite heavy, it is easily manipulated, being sus- 
pended from the ceiling by means of a counter-weight. The 
concussors are of different sizes to include one, two, three or 
more spinous processes. The apparatus in question is only 
available when compressed air of considerable pressure can 
be obtained, but this is rarely objectionable insomuch as all 
modem oflBce buildings are equipped with air compressors. 

Smaller pneumatic hammers are procurable, but they can 
only be regarded as mere toys for the elicitation of the verte- 
bral reflexes. 

An eflBcient percussion -stroke may be obtained from an 
electric apparatus (Fig. 51). It strikes from 3,500 to 5,000 
blows per minute, and the force of the blow varies according 
to the pressure on the spine by the concussor in the vibrator 
from an imperceptible to the maximum blow. It is run with a 
J H. P. and may be arranged for any kind of an electric 
current. The only objectionable feature is its price (about 
$160). 

If the physician cannot obtain an efficient apparatus, then 
a hanuner and pleximeter (Fig. 2 ) may be used with fairly 
good results. In the excellent book** of Doctor M. L. H. 
Arnold Snow, the author specially cautions the reader to 
avoid the spinous processes in the application of vibration. 
In my opinion, this caution is absolutely unnecessary. Many 
times a day, for years, the author has concussed the spinous 
processes most unmercifully, yet he has never noted any un- 
toward results. His experience in this regard, prompts him 
to side with those who hold that spinal concussion and 
cerebral commotion cannot give rise to the symptoms of a 
traumatic neurosis, for otherwise, many of his patients would 
have been the victims of "railway spine," insomuch as they 
have been subjected to as much concussion as they would 

178 



S p n d y I the r a p y 

have experienced in several railroad accidents without suffer- 
ing from any untoward results * 

It will be noted in the special chapters that vibra-massage 
is, in some instances, more efficient than the sinusoidal 
current for the elicitation of the vertebral reflexes. It may 
also be noted, that if treatment with either method is too 
prolonged, the spinal visceral reflexes become exhausted and 
a condition other than that sought for will result. Experience 
only will determine the time necessary for each treatment, 
although the relief of symptoms is a fair gauge for the dura- 
tion of a stance. 

Reference has been made on page 169 to the increase of 
temperature following massage of the spine, but in the 
opinion of the author, concussion with the pneumatic hanuner 
is decidedly more efficient. Concussion of any of the 
spinous processes will elevate the temperature, but the best 
results are achieved when the spinous process of the 7th 
cervical vertebra is concussed. The two following cases of 
myocarditis are cited to show the effects of concussion on the 
spinous process of the 7th cervical vertebra: 

CASE I. 

Temperature before concussion 97. 2® F. 

" after " for 4 minutes ..98** F. 

" 8 " ..98.8*>F. 

CASE II. 

Temperature before concussion 96. 4® F. 

" after " for 4 minutes... 98® F. 

No such effects could be produced with the sinusoidal 
current. 

*The fear of employing forcible concussion on the spinous processes and the \iae 
of inefficient apparatus are responsible for the inefficient results achieved by 
vibra-massage. 

180 



Vibratory Massage 

The author does not believe that elevation of temperature 
following concussion of the 7th cervical vertebra is dependent 
on stimulation of a problematic thermogenic center, but to 
a stimulation of the heart (heart reflex). 

In fever ^ the author has never succeeded in reducing the 
temperature by aid of concussion of any of the spinous 
processes, although his efforts have been many. The 
employment of concussion to induce analgesia is discussed 
on page 367. 



181 



Spondylotherapy 



CHAPTER VI. 

PSEUDO -VISCERAL DISEASES. 

NEURALGIA — ^INTERCOSTAL NEURALGIA — DIFFERENTIAL DIAGNOSIS — 
PSEUDO-APPENDICITIS — ^PSEUDO-CEREBRAL DISEASE — ^PSEUDO-AN- 
GINA PECTORIS — ^PSEUDO-ARRHYTHMIA — PSEUDO-ESOPHAGISMU8 
— ^PSEUDO-NEPHROLITHIASIS — PSEUDO-DYSPEPSIA — PSEUDO- 
CHOLELITHIASIS — ^PSEUDO-MAMMARY NEOPLASMS. 

17 VERY physician owes a modicum of his success to the 
■■^ recognition and successful treatment of some special 
disease. In this respect, the author's talismanic affection is 
neuralgia of the spinal nerves with their bizarre and protean 
manifestations. The author may be pardoned for his 
apparent presumption when he asseverates that he feels 
justified in having written this book, if for no other reason 
than to direct the attention of the profession to recognize the 
greatest simulator of visceral diseases, viz., neuralgia of 

THE SPINAL NERVES. 

It very frequently happens that neuralgia of the spinal 
nerves may be accompanied by visceral symptoms of such 
prominence that the neuralgia is overlooked and unsuccessful 
treatment is directed toward the supposititious visceral 
disease. Such cases, while presenting varied clinical pictures, 
are frequently analogous, if only atypically so, to gastric, 
cardiac, renal, vesical and intestinal affections. The 
neuralgic paroxysms occurring in spinal diseases like tabes 
are manifested by symptoms occurring in organs like the 
stomach, intestine, bladder, etc. Here, like in neuralgias of 
the spinal nerves, we are dealing with lesions represented by 
nerve-root symptoms. Many pseudo-visceral diseases may 
be partially explained by the anastomosis existing between 

182 



Pseudo-Visceral Disease 



the spmal and sympathetic nerves (^nde syinpathetic sensa- 
tions, page 57). Neuralgia of the intercostal nerves most 
frequently simulates visceral disease. 

The upper group of the thoracic nerves is distributed 
entirely to the thoracic wall and the lower group (7th to nth) 
is distributed partly to the thoracic and partly to the abdom- 
inal walL It is the latter fact which often makes the recog- 



OfTtltl/AL BRAKCH 




Fig. 51. — Ditignm ol tlie diitiibution of a typio.1 thoracic 



nition of intercostal neuralgia difficult, insomuch as the word 
intercostal (between the ribs), connotes an erroneous topog- 
raphy in the localization of pain. It is evident that in dis- 
eases affecting the nerve-trunks at or neartheirorigin.thepain 
is referred to their peripheral terminations. Thus, in Pott's 
disease of the spine, the pain is referred to the belly, owing 
to the irritation of the nerve-trunks at their origin. In 
183 



S p 



d 



I 



t h 



a p 



pneumonia or in pleural affections, the pain may be referred 
to the abdomen or the right iliac fossa and may suggest 
appendicitis. Here the lower thoraco-abdominal nerves are 
irritated owing to their juxtaposition to the pleura. 




A typical thoracic nerve is shown in Fig. 52. In the 
posterior parts of the intercostal spaces, muscular branches 
are distributed to the levatores costarum and the nerves pass 
forward between the external and internal intercostals and di- 
vide into: I. Lateral branches, which after penetrating the 
external intercostals near the mid-axilliary line, divide into 
anterior and posterior branches. 2. Anterior branches, 
which at a short distance from the sternum give off ten 
184 



r 



Neuralgia 

^ir^ches. Fig. 53 shows the cutaneous nerves of the thorax 
^^d abdomen. 

To properly appreciate this subject it will be necessary 
ftrst to describe neuralgias in general and later intercostal 
neuralgia in particular. 

NEURALGIA. 

Neuralgia is usuaUy a unilateral affection associated with 
paroxysmal pains and painful areas {points douloureux) on 
pressure at certain points in the course of the nerve where 
the latter passes through bones, muscles, or lies superficially. 
The painful areas are also present in the interparoxysmal 
periods. 

Associated symptoms of neuralgia are : disturbances of 
sensation (hyperesthesia or anesthesia), vaso-motor symp- 
toms, anemia or hyperemia of the skin and increase of the 
secretions, trophic disturbances and localized clonic spasm 
of the muscles. 

The pains in neuralgia are usually localized to a single 
nerve, but at the height of the paroxysm the pains may 
radiate to other nerves. 

Muscular pains show diflFused areas of tenderness in 
the muscles, are dependent on movement and are not 
paroxysmal. 

Malaria has often been accused as an etiological factor 
in neuralgia because the pains are paroxysmal, but this is an 
erroneous supposition insomuch as the pains of neuralgia, 
irrespective of cause, are paroxysmal. 

Again, syphilis is accepted as a cause because the parox- 
ysmal onset occurs at night. But this feature is common to 
many neuralgias. On the other hand, the absence of noc- 
turnal exacerbations speaks against syphilis. 

Among the more frequent etiologic factors of neuralgia are : 

185 



S P 



d y I 



t h 



a p y 



I. Mechanic ([H'cssure on nerve from growths, exuda- 
tions, etc). 

3. Thermic (chilling draughts, etc). 

3. Toxic (drugs, infectious diseases and nutritive 
disturbances). 

One must not forget that, whereas in the majority of 
instances intercostal neuralgia is primarily due to cold (with 
the lesion at the vertebral exit of the nerve), it may be second- 
ary to vertebral disease, spinal meningitis and pressure from 
an aneurysm, tumor, etc.* 

INTERCOSTAL NEURALGIA. 

As before remarked, the diagnosis of this affection is not 
diflficult when the middle intercostal nerves are involved; 
the difficulty arises when the lower group is involved, owing 
to the distribution of the nerves to the skin of the lateral and 
anterior abdominal wall. 

In intercostal neuralgia three painful points are invariably 
found on pressure, viz., at the vertebral exit of the nerve, in 
the mid-axillary line and in the median line of the thoracic 
and abdominal walls. The point at the vertebral exit is 
most constant and the method for the elicitation of the pain 
or tenderness has already been described on page 66. Here 
a word of caution is necessary. Unless the muscles are 
relaxed the contracted muscular fibers over the areas of 
tenderness will prevent elicitation of p 




Intercostal Neuralgia 

the point first from above and, when the sensitive area is 
reached, it is marked with a dermograph (skin -pencil). 
Next we locate the sensitive area from below and, when the 
latter is reached, it is also marked. It is wise to compare 
the sensitiveness on both sides of the spine although, as a 
rule, the neuralgia is unilateral. 

The author makes exclusive use of freezing (page 172) 
for diagnostic and therapeutic purposes. The area to be 
frozen in neuralgia of a spinal nerve or nerves is that included 
between the two pencil marks just referred to. 

It will be noted that if the mid-axilliary and sternal 
points of tenderness are marked with a pencil and freezing 
is executed at the vertebral point, the other points of tender- 
ness disappear, or will be, at least, less sensitive after a single 
freezing. 

This latter test is diagnostic of neuralgia of any of the 
spinal nerves. Several freezings, however, may be necessary 
before the neuralgia is cured. 

In practically every case the author ever saw, when a 
diagnosis of neuralgia of a spinal nerve was made, the attend- 
ing physician had applied his counterirritant at the site of 
the pain, i. e.y at the peripheral distribution of the nerve and 
not as he should have done near the site of the lesion, viz., 
the vertebral exit of the affected nerve. 

If the negative pole of a Galvanic current is fixed at an 
indifferent spot, and the positive pole is placed successively 
over the other sensitive points, neuralgic pain is likewise in- 
hibited, but this method cannot compare in accuracy nor in 
rapidity with the freezing method. 

The author has often utilized the following method in 
the absence of a freezing apparatus ; firm pressure is made 
with the thumb and maintained for several minutes at the 
vertebral area of tenderness. At first, the pains are accen- 

187 



S p ondylotherapy 

tuated, but later they are mitigated or disappear. The 
method cited is used in an emergency and is decidedly less 
radical than freezing. Reference has been made to it on 
page 171. 

It may happen, and indeed it often does, insomuch as 
cold is the common etiologic factor of neuralgia and muscular 
rheumatism, that both affections coexist. Here Faradism 
temporarily inhibits the pain of rheumatism, leaving the pain 
from other causes uninfluenced. Again, Faradism will 
accentuate the painful areas of muscular rheumatism. 

Congelation (freezing) may be employed as a means of 
diagnosis for the following purposes : 

A. To diagnose neuralgia of central from one of 

peripheral origin. 

B. To differentiate neuralgia from neuritis. 

C. To localize the lesion in neuralgia. 

A. If a nerve the seat of neuralgia is frozen nearest its 
point of origin, the pain will disappear if the neuralgia is of 
peripheral origin and it will persist if of central origin. In 
the absence of spontaneous pain the painful points in the 
course of the nerve-distribution may serve as guides. 

B. Freezing is a specific for all forms of uncomplicated 
neuralgia, provided it can be executed near the point of 
origin of the involved nerve, i, e.y close to the site of the 
lesion. If, however, the pain is central in origin or due to a 
neuritis, the pain, as a rule, will not be inhibited. Many 
years ago I suggested freezing for the pains associated with 
herpes zoster. In some instances it was marvelously efficient, 
but in the majority of cases, no relief followed. Here the 
pain was of central origin, due presumably to disease of the 
intervertebral ganglion. 

C. The following cases illustrate the employment of 
freezing for localizing pain : 

188 



Intercostal Neuralgia 

Case I. Male. In a row received many cuts on the 
scalp. Various cicatrices resulted. He suffered 
from ill-defined neuralgia located in the scalp. All 
cicatrices were equally sensitive to pressure. 
Freezing was conducted at the exit of the occipital 
nerves in the neck without effect. Then the indi- 
vidual scars were successively frozen during a 
paroxysm. Pain continued until one cicatrix in the 
occipital region was frozen, when the pain ceased 
at once. Excision of the latter cicatrix resulted in 
cure. 

Case II. Case of occipital neuralgia. Usual painful 
points. Freezing conducted during a painful 
paroxysm. When freezing was made over a particu- 
lar sensitive point the pain ceased. Palpation at 
this point demonstrated the presence of a little 
growth. Cure after removal of a small neuroma. 

Case III. Neuralgia of the trigeminus (prosopalgia). 
Freezing during a painful paroxysm at the supra- 
orbital foramen, infra-orbital foramen and mental 
foramen respectively. Relief from the pain when 
congelation was conducted at the latter point. 
Examination of the teeth of the lower jaw showed 
the presence of a carious tooth, which, when ex- 
tracted, was followed by a cure. 

DIFFERENTIAL DIAGNOSIS. 

Visceral diseases are frequently confounded with inter- 
costal neuralgia. Here, as a rule, we find only a vertebral 
area of tenderness, whereas the mid -axillary and sternal 
points of tenderness are absent. Again, freezing at the 
vertebral area of tenderness is not followed by any relief of 
the pain. In visceral disease simulating intercostal neuralgia, 
one may demonstrate dermatomes (page 58) which, like 
the vertebral tenderness, become accentuated after palpation 
of special organs. Supposing, for example, one finds a 

189 



Spondylotherap 



sensitive area over the stomach. If pressure sufficientlj^ 
great is made at this point to induce pain, the area of verte — 
bral tenderness in my experience, becomes accentuated and 
the dermatomes are more easily demonstrated. 

In localizing the latter, however, one must not forget that 
hyperesthetic zones may also be demonstrated in neuralgia. 

As a rule, in visceral disease, vertebral tenderness may 
be demonstrated on both sides of the spinal column, whereas, 
in intercostal neuralgia, the sensitiveness is unilateral. 
Bilateral sensitiveness in the latter aflFection suggests an 
intravertebral lesion. 

Whereas, in intercostal neuralgia, pressure on the area of 
vertebral tenderness may reproduce the pains from which the 
patient suffers, in vertebral tenderness of visceral origin, like 
pressure may reproduce other symptoms. Thus arrhythmia 
may be reproduced or accentuated when the area of vertebral 
tenderness is firmly compressed. Similarly, in gastric 
disease, pressure on the sensitive vertebral area may cause 
eructations of gas and other symptoms suggestive of a 
gastric anomaly. 

The aphonia and dysphonia of laryngitis (acute) may 
be differentiated from like symptoms due to other laryngeal 
affections by the following simple method: First, mark 
with a pencil on either side of the neck the approximate 
point in the thyro-hyoid membrane where the internal 
laryngeal branch of the superior laryngeal, the nerve of 
sensation to the larynx, passes into the latter organ. Next, 
thoroughly freeze the points marked with the pencil. Relief 
is, as a rule, almost instantaneous and is of signal advantage 
to many professionals. In some instances, the restoration 
of the voice is of only short duration and freezing may have 
to be repeated several times. 

The author desires to illustrate by the citation of a few 

190 



s e u d - A p p en die i t i s 

^^^Scs what he intends to convey by the phrase, p^udovisceral 
disease. In this respect he will be brief, for in this epoch of 
'therapeutic skepticism, one dare not report phenomenal 
^res without being accused of extravagant representation, 
^^interpretation or, if the calumniator is charitable, of 
auto-suggestion. 

PSEUDO -APPENDICITIS . 

LuMBO-ABDOMiNAL NEURALGIA which involves the six 
branches of the lumbar plexus is frequently mistaken for 
appendicitis. The author has observed many patients who 
had even contemplated an operation for the relief of their 
pain, but who were cured after one or several freezings at 
the vertebral exits of the sensitive nerves. One patient in 
particular is recalled who was seen in consultation, and who, 
despite the protests of the author, had his appendix removed. 
After the operation the persistent pains of a lumbo-abdom- 
inal neuralgia were cured by several freezings. 

These cases are not difficult to diagnose. Painful areas 
are located near the lumbar portion of the vertebral column, 
in the center of the iliac crests, over the symphysis in the 
hypogastric region, at the scrotum in the male and at the 
labium majus in the female. 

Pain in these patients is also felt on the anterior surface 
of the thigh corresponding to the area of distribution of the 
lumbo-inguinal nerve. 

Difficulty in diagnosis in these cases is often hampered 
by the fact that there is a circumscribed tonic spasm of the 
abdominal muscles in the ileocecal region which may be 
mistaken for a deep-seated intumescence. 

We have long recognized the almost intelligent function of 
muscles whether displayed in fixing a diseased joint or spine, 
or in protecting an inflamed serous membrane. The fact is, 
that in spinal neuralgias, spasm of the muscles can almost 

191 



Spondylo therapy 

invariably be demonstrated and it is a nerve-root symptom. 
When the lesion, as in neuritis, is destructive rather than 
irritative, muscular atrophy and not spasm is the con- 
comitant sign. 

One would naturally conclude that a skilled diagnostician 
could not possibly err in mistaking a lumbo-abdominal 
neuralgia for appendicitis. In Paris, the author recently 
saw an American lady who was suflFering from atrocious 
pains in the ileocecal region. She consulted some of the 
leading surgical and medical clinicians of Europe. All were 
unanimous in their conviction that she had appendicitis, and 
that an immediate operation was imperative and the only 
means of arresting the pains. An examination demonstrated 
the spasm of the abdominal muscles in the neighborhood 
of the appendix, which, at one point, was so circumscribed 
as to awaken the suspicion of a tumor. A point over the 
appendix was exquisitely tender. There were the usual 
tender points elsewhere in the gluteal region, on the outside 
of the thigh, symphysis pubis and at the vertebral exits of the 
involved nerves. A single freezing gave inmiediate relief, 
although about ten freezings were necessary to effect a 
permanent cure. These patients often suflFer a relapse, 
especially in inclement weather, but a single freezing 
suffices to cure. My only excuse for citing the latter case is 
to illustrate the frequency of pseudovisceral affections which 
are often erroneously interpreted by some of the best men 
in the profession. Verily, if the surgeon were a better 
diagnostician there would be less surgery. 

PSEUDO -CEREBRAL DISEASE. 

When a neuralgia implicates respectively the four superior 
cervical nerves, it is referred to as cervico-occipital neuralgia 
and the four inferior cervical nerves, as a cervico-brachial 

192 



P s e u do - Mastoiditis 

neuralgia. In the former neuralgia, the major occipital 
nerve is most frequently involved and the pain is located in 
the neck and radiates along the occipital region as far for- 
ward as the eyes. There is practically always a spasm of the 
cervical muscles which interferes with the elicitation of pain 
upon deep pressure at the vertebral exits of the implicated 
nerve or nerves. Not infrequently, branches of the brachial 
plexus are similarly involved and the pains radiate down 
the arms. In cervico -occipital neuralgia, localized areas of 
sensitiveness may be detected notably at the external occipital 
protuberance and at the tip of the mastoid process. The 
latter point of sensitiveness has, in my experience, often been 
mistaken for a mastoiditis by enthusiastic aurists, yet a 
single freezing at the verterbal exits of the involved nerves 
will determine the nature of such forms of pseudo-mas- 
TOiDins. Pseudo-jnastoiditis is frequently mistaken for the 
true form of the disease if a discharge from the ear (otorrhea) 
IS present. 

When the pathologist makes an autopsy he records the 
many pathological conditions as anatomic diagnoses. The 
clinician should be similarly guided, but, unfortunately, he 
too often errs in tracing a connection between varying 
symptoms in his eflFort to include them all in a single diag- 
nosis. Co-existing symptoms may be the expression of not 
only one but of several distinct diseases. The following case 
will amply illustrate the author's meaning: A gentleman 
having fallen from a ladder sustained an injury of the spinal 
column which resulted in a kyphotic deformity. Several 
weeks later he developed atrocious pains in his right leg 
which several orthopedists attributed to the original injury. 
Examination of the patient in question demonstrated a 
sciatica which had absolutely no connection with the primary 
traumatism and after several freezings over the region of 

193 



S p n d y I t h e r a p y 

the nerve, the pains subsided completely and have ceased 
to reappear after several years, notwithstanding the per- 
sistence of the spinal deformity. 

About four years ago one of my tabetics returned from 
Europe suffering from severe pains in the head which several 
specialists had told him were dependent on a cerebral lesion. 
The pains resisted conventional treatment. Examination of 
the patient, who returned to San Francisco in despair and 
without relief, demonstrated the presence of a cervico- 
occipital neuralgia. The localized areas of sensitiveness on 
his scalp disappeared after a single freezing at the vertebral 
exits of the involved cervical nerves and cure resulted after 
a thorough repetition of the procedure. 

A lady with pains in the left half of the abdomen con- 
sulted several gynecologists, all of whom discovered a pro- 
lapsed ovary and suggested its removal. The pains due to a 
lumbo-abdominal neuralgia continued after the operation 
and were cured after several freezings at the exits of the 
involved nerves. 

PSEUDO -ANGINA PECTORIS. 

An intercostal neuralgia is frequently misinterpreted for 
angina pectoris. In the latter affection pains radiate to the 
neck and arm. The investigations of Head and Mackenzie 
show the following : 

1. In cardiac and aortic disease, the pain is referred 
along the ist, 2nd and 3rd dorsal nerves. 

2. In angina pectoris, the pain in addition may be 
referred from the 5th to the 9th dorsal nerves. 

The forms of anginal pains referred to in this connection 
are not concerned with functional angina pectoris observed 
in neuroses, but are distinctly traceable to a neuralgia of 
the intercostal nerves. 

194 



Pseudo-Arrhythmia 

About fifteen years ago an elderly individual was referred 
to me by an Eastern physician with a diagnosis of angina 
pectoris. Several prominent clinicians had made a similar 
diagnosis. Like in true angina, the conmion exciting factor 
in provoking a paroxysm of pain in this patient was exposure 
to cold. Despite the concomitant symptoms which suggested 
the correctness of the diagnosis, the patient was examined 
for the signs of intercostal neuralgia which could easily be 
demonstrated. A few freezings at the vertebral exits of the 
involved nerves suflSced to rid the patient of his pains which, 
up to the time of writing, have not recurred. 

PSEUDO -ARRHYTHMIA . 

An irregular heart may be clinically manifested as an 
intermission when one or more beats of the heart are dropped, 
or, as an irregularity, when the beats show inequality in 
volume and force. The causal classification of Baumgarten 
is as follows: 

1. Organic cerebral affections. 

2. Reflex from visceral diseases. 

3. Toxic, from tobacco, coffee, tea and from drugs like 
digitalis, belladonna and aconite. 

4. Changes in the heart. 

Arrh)rthmia may exist for a long period without 
symptoms. It is usually in connection with other cardiac 
signs that its presence is noted. Associated with myocardial 
or valvular lesions it is ominous, but as a permanent con- 
dition, secondary to mental influences, it is usually without 
significance. Irregularity of the heart -rhythm may give no 
expression in the pulse. The purely neurogenic type of 
irregularity observed in healthy children and young adults 
is due to overaction of the vagus. When the latter is para- 
lyzed by atropin (grain 1-120 to 1-60), the pulse becomes 

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Spondylotherapy 

regular. Heart intermittency is diflferentiated from simple 
irregularity, by the fact, that, in resumption of the cardiac 
contractions they are regular from the beginning. 

The author has demonstrated that, in the norm during 
the time the pulse is palpated, firm pressure made at the exit 
of the spinal nerves (preferably at the sides of the upper 
dorsal vertebrae), will result in decided alteration in the 
character of the pulse which often amounts to inhibition of 
the latter. In a few instances a decided arrh)rthmia may be 
observed. 

The observations of the author have taught him that a 
neuralgia of the upper intercostal nerves is not an infrequent 
etiologic factor in arrhythmia notwithstanding the fact that, 
this cause is unrecognized in the text-books. 

In intercostal neuralgia associated with arrhythmia, 
pressure on the sensitive areas corresponding to the exits of 
the involved nerves will accentuate the condition, and, if 
absent, will provoke it. 

In such instances of arrhythmia, a single freezing at the 
vertebral exits of the involved nerves will often arrest the 
trouble at once. Arrhythmia may also exist as a result of a 
nerve-root lesion of the upper group of dorsal nerves without 
any symptoms of intercostal pains. 

PSEUDO-ESOPHAGISMUS. 

The following case, selected from many cases of a similar 
nature, is interesting as a paradigm of this condition. The 
patient, a female, has suffered for months in consequence of 
painful deglutition and is very much emaciated in conse- 
quence of her difficulty in swallowing not only solid foods, 
but liquids. An examination was negative beyond pain on 
pressure in the cervical region with sensitive cervical vertebrae 
on percussion. There were no symptoms of hysteria. The 

196 



^ s e u d - VisceralDiseases 



ijrsphagia disappeared completely after three applications 
of the freezing-spray to the region of the sensitive cervical 
nerves. 

PSEUDO-NEPHROLirHIASIS. 

The patient, a physician, had suffered for many years 
from pains in the lumbar region on the right side occurring in 
paroxysms and simulating the pain of renal colic. An 
exploratory incision down to the kidney was made by an 
eminent surgeon of Philadelphia, and nothing was found. 
When the patient came to me his pain still persisted. The 
first and second lumbar vertebrae were sensitive to percussion 
and areas of vertebral sensitiveness were located to the right 
of the spinal column. Successive freezings of the para- 
vertebral area of sensitiveness checked the painful parox- 
ysms completely. 

PSEUDO-DYSPEPSIA. 

There are many cases which I have denominated fictitious 
dyspepsia^ which are comparatively frequent and are asso- 
ciated with involvement of the spinal nerves. The patients 
may exhibit all the symptoms of d)rspepsia, yet the presence 
of the painful areas of sensitiveness of an intercostal neuralgia 
are demonstrable. These cases, like the others, yield to 
freezing. 

PSEUDO -CHOLELITHIASIS. 

About several months ago several surgeons had made the 
diagnosis of gall-stones in an adult male, who for several 
years had suiBFered from paroxysmal pains in the region of 
the gall-bladder. Before submitting to an operation he 
decided to consult three medical clinicians. We also con- 
curred in the diagnosis. The author was reluctant to question 
the diagnosis for the reason that the severe paroxysms of 
pain necessitated the use of morphine. When pain is severe 

197 



I 



S p n d y I t h e r a p y 

SB:^^BSBBS^SBaaaBSSBBrBBBBBBBSBI^BBBBBBSBSBSBBBBSS:^^BI^BBS 

enough to necessitate an analgesic so powerful as morphine 
(in the author's experience) intercostal neuralgia can be 
excluded. On the following day, the patient in question 
was re-examined and the areas of sensitiveness peculiar to 
intercostal neuralgia could be demonstrated. About ten 
freezings over the vertebral exits of the implicated nerves 
suflBced to completely rid the patient of his paroxysms of 
pain. In fact, after the first freezing, the painful area 
located near the gall-bladder was no longer sensitive to 
pressure. 

The author has seen a niunber of such cases and one case 
in particular is recalled, where jaundice accompanied the 
painful paroxysms. The jaimdice in the latter case could 
be explained by the fact that respirations on the aflFected 
side were limited. It is well-known that the bile is secreted 
imder very low pressure and that the diaphragm in contract- 
ing, subjects the liver to pressure which is an active factor 
in forcing the bile from the smaller to the larger biliary 
ducts. Interference with the movements of the diaphragm 
is likely to cause icterus of resorption. 

PSEUDO -MAMMARY NEOPLASMS. 

As before remarked, neuralgia of the intercostal nerves 
is associated with a circumscribed tonic spasm of muscle and, 
if the neuralgia involves the nerves in juxtaposition to the 
mamma, the pain and intumescence suggest a neoplasm. 
In such instances, an error is unavoidable, unless the phys- 
ician recalls the fact, that mastodynia may be a variety of 
intercostal neuralgia. 



198 



The Heart Reflex 



CHAPTER VII. 

THE CIRCULATORY SYSTEM. 

THE HEART KEFLEX — CARDIAC SUFFICIENCY — DIFFERENTIAL TABLE OF 
ASTHMA — ^TESTS FOR HEART-SUFFICIENCY — ANGINA PECTORIS — 
THE HEART REFLEX OF DILATATION — DIFFERENTIAL TABLE OF 
TRUE AND FALSE ANGINA — FUNCTIONAL AFFECTIONS OF THE 
HEART — ^INHIBITION OF THE HEART — ^PHYSIOLOGY AND PATH- 
OLOGY OF THE BLOOD-VESSELS — BLOOD-PRESSURE — VASO-MOTOR 
FACTOR IN BLOOD-PRESSURE — SPHYGMOMANOMETRY — HYPERTEN- 
SION AND HYPOTENSION — THE AORTIC REFLEXES — ANEURYSM OF 
THE THORACIC AORTA — THE VASO-MOTOR APPARATUS — VASO-MOTOR 
NEUROSES. 

THE HEART REFLEX. 

A TTENTION was first directed in 1898 to the phenom- 
-^^ enon*^ now known as the heart reflex of Abrams. The 
reflex in question is a contraction of the myocardium of 
varying duration, which results when the skin of the pre- 
cordial region is irritated. The cutaneous irritant may be 
a spray of ether directed over the region of the heart, or the 
skin may be rubbed with a blunt instrument, or by means 
of an ordinary pencil eraser, or by a series of percussion 
blows. The nearer the irritant is applied to the precordial 
region and the more vigorous the cutaneous friction, other 
things being equal, the more pronounced is the heart reflex. 
The reflex is best observed with the Roentgen rays with the 
fluorescent screen approximating the anterior chest-wall. 
The reflex is, as a rule, more manifest in the left than in the 
right ventricle, and the contraction of the myocardium is 
not always sudden and of momentary duration; on the 
contrary, its duration in children, on whom most of the 
original observations were made, is not less, as a rule, than 

1 



I 



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t h 



r a p y 



two minutes, and, furthermore, the myocardial recession 
continues even after the source of cutaneous irritation is 
removed. The degree of myocardial recession (heart 
reflex) varies greatly. In some persons it is scarcely percep- 
tible, while in other individuals the heart may recede more 
than 2 cm. on either side upon the first application of the 
cutaneous irritant (Fig. 54). 




Fig. 54. — Heart reflex in a boy, aged eight years. Duration of reflex two and 
a half minutes. The normal outline of the heart drawn on the fluoroscope is 
represented by A, whereas B represents the outline of the heart after cutaneous 
irritation and shows the degree of myocardial recession of the heart reflex. 



In other instances, although the reflex is practically never 
absent in the norm, it is strictly confined to the left ventricle, 
as shown in Fig. 55. 

In individuals with dilated hearts the reflex is very 
evident and is of much longer duration than in healthy hearts. 
This latter observation, as we shall learn presently, has been 
confirmed by the careful observations of Merklen and Heitz. 

In the original communications concerning the heart 

200 



T h 



H 



a 



R e f I e X 



reflex, the latter was only observed in the transverse cardiac 
diameter, but with the x-rays it can also be seen in the 
sagittal diameter. Subsequent observations demonstrated 
that the heart reflex could be elicited by irritation of more 
remote regions, viz. : 



I. 

2. 

3- 
4. 

5- 
6. 



Irritation of the nasal mucosa. 

Irritation of the gastric mucous membrane. 

Irritation of the rectal mucosa. 

By irritation of the esophageal mucosa in the act of 

swallowing. 

By percussion of the muscles. 

By psychic influences. 

By vertebral concussion. 





Fig. 55. — Heart reflex in a boy, aged fourteen years. Duration of reflex, fifteen 
seconds. A represents the cardiac outline before, and B after, cutaneous irritation, 
while C represents the upper border of the liver. 

Irritation of mucous membranes. — Here investiga- 
tions were conducted during the time the x-rays were tra- 
versing the chest, and by means of the fluoroscope the 
heart was directly observed. It was noted that, when irri- 
tating vapi«rs were inhaled there was a decided recession of 
the cardiac ventricles (heart reflex), especially the left, and 
that this heart reflex was more pronounced than when 

201 



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excited through the skin of the precordium. Ether and 
chlorofonn inhalations also excite the reflex and in a few 
instances, these vapors produced a veritable cardiac in- 
hibition. It was noted that, the reflex in question was excited 
by irritation in succession of- the nasal, pharyngeal and 
laryngeal mucous membranes, and when the latter were made 
anesthetic by cocain, no heart reflex could be elicited. 

The accompanying sphygmogram (Fig. 56) shows a 
decided difference in the output into the general circulation 
before and after the inhalation of ammonia. 

The heart reflex may also be elicited by irritation of the 
gastric mucosa when the sponge of the gyromele is made to 



I before, and B after, the in- 



revolve against the membrane in question. One may also 
excite the reflex by irritation of the rectal mucosa by means 
of the finger in the rectum. 

pERcussioN OF THE MUSCLES. — If One percusscs the 
muscles {tapotemenl') of the extremities, one can elicit the 
cardiac rctle.x. The latter is essentially a reflex of muscular 



The Heart Reflex 

to percuss the muscles of one arm by means of a percussion- 
Iiaimner. Following the manceuver the right ventricle shows 
considerable retraction. The effect on the systemic blood - 
pressure by percussion of the muscles is very slight, and 
this is obvious, considering that the left heart-ventricle is 
uninfluenced by the manceuver. 

Psychic influences. — We have always recognized the 
influence of emotions on the heart, but no tangible evidence 
of such effects has been demonstrated. The epigram of 
Peter is worth repetition : "The physical heart is the counter- 
part of a moral heart." The conventional expression of the 
frightened individual, **My heart was in my mouth," finds 
justification by an x-ray study of the organ. Inform the 
j)atient standing before the x-rays, that you are going to 
bum him with a hot iron or frighten him in some other way, 
and the effect on the heart is at once manifested. It is a 
veritable psychic heart reflex implicating the entire organ. 
The heart becomes very much reduced in size, and appears 
as if it were retreating towards the neck. I know of no 
irritation, cutaneous or otherwise, that is so pronounced as 
this psychic factor of fright in inducing the heart reflex. The 
foregoing fact is of the utmost importance in eliminating 
emotional influences in the treatment of cardiac diseases. 
Even in an ordinary x-ray examination of the heart, one 
may observe in nervous patients a reduction of the heart- 
mass, Mr. Bezley Thome^^ observed that the heart shrank 
after exposure to the Roentgen rays. It is evident that the 
shrinkage thus observed, was naught else but a cardiac re- 
action (heart reflex) to emotional influences, for an x-ray 
examination to the average patient is a momentous procedure. 
The author has frequently witnessed the pulmonary 
reaction of fright ; the lungs became hyperresonant on per- 
cussion and the superficial areas of cardiac, hepatic and 

203 



S p ondylotherapjf 



splenic dullness became diminished, a condition which 
author has called the ^psychic lung reflex of dilatation. Th»-^ 
latter psychic reflex may be easily demonstrated, if \im^^ 
areas of the organs in question are first outlined, and lateir" 
if the patient is frightened, percussion will demonstrate tha^ ^ 
the areas of the organ are reduced in proportion to the psychic 
reaction which provokes a dilatation of the lungs. 

Vertebral coNCUSSiON.^Perhaps the most efltectiv^ 
method of provoking the heart reflex is by means of con — 
cussion of the spinous process of the 7th cervical vertebra- 
It will be noted that this refers to the heart reflex of con- 
traction, for there is still another heart reflex which is to be 
described presently, known as the heart reflex of dilatation. 

Practical value of the heart reflex. — Percussion of 
heart, or, for that matter, any other organ adjacent to the 
lung, is associated with many errors imless one takes into 
consideration the lung reflex. 

Percussion of the heart, as executed ordinarily, )delds an 
absolute or superficial, and a deep or relative dullness. 
Practically little or no value can be attached to the superficial 
dullness in estimating the size of the heart, as it varies with 
the position of the overlapping limg-borders. Even the 
lightest percussion blow will provoke suflBcient cutaneous 
irritation to induce the lung reflex of dilatation, i.e., an acute 
dilatation of the lungs which may diminish the area of 
superficial cardiac dullness, even to obliteration. Cabot," 
in his classical book, makes the following observation : "Any- 
one who has demonstrated an area of percussion dullness to 
many students in succession must have noticed occasionally 
that the more we percuss the dull area the more resonant it 
becomes, so that those who last listen to the demonstration, 
the difference which we wish to bring out is much less 
obvious than to those who heard the earliest percussion 

204 



The Heart Reflex 

strokes. Abrams has referred to this fact under the name of 
the ^lung reflex,'* " Sahli, in his "Diagnostic Methods," 
refers to the same fact. The mere influence of room tem- 
perature materially changes the results of percussion. Let 
any one, after percussing the areas of superficial dullness, 
direct a current of cold air, e.g., from an atomizer, over the 
regions percussed, and the result will be diminution or 
obliteration of the areas in question. It is evident from what 
has preceded that, while the heart reflex can always be 
determined by the x-rays, after cutaneous irritation of the 
precordium, mere percussion of the superficial area of cardiac 
dullness cannot determine its existence because the irritation 
necessary to evoke the heart reflex will also induce the lung 
reflex, which must necessarily mask the heart reflex. 

Thus the observations of Schott and others, who seek to 
demonstrate the effects of carbonated baths on the heart by 
percussion of the latter organ are evidently erroneous unless 
such percussion takes into consideration only the deep or 
relative cardiac dullness. Hei tier ^' perpetrates the same error 
by failing to take into consideration the coincident lung 
reflex when making cutaneous irritation. Heitler seeks to 
determine the sufficiency of the heart muscle by a series of 
percussion blows over the heart region. If, thereafter, the 
cardiac dullness is much diminished, it is an evidence, he 
argues, that the cardiac musculature is suflScient, for the 
tendency of the normal muscle tonus of the heart is to 
maintain a limited patch of dullness. As before remarked, 
the heart reflex can be observed directly with the rays, but 
if strong percussion is employed so that reliance is alone 
placed on the deep or relative cardiac dullness, the reflex in 
question may be determined by percussion. Heitz,^^ in 
discussing "Le Reflexe Cardiaque d'Abrams," observes that, 
while in the normal subject the heart reflex is of short dura- 

205 



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tion, in cardiectasis it may persist for several hours. In the 
third edition of their valuable book ("Examen et S6m6iotique 
du Coeur"), Merklen and Heitz show graphically the effects 



© 




Fig. 57. — Cardiac reflex in a neurasthenic with functional troubles of the 
heart; reduction of the absolute and relative dullness. (After Merklen and Heitz). 

of friction of the skin in the region of the heart of a cardiac 
neurasthenic (Fig. 57), and in a cardiopath with hyposystolie 
(Fig. 58). 



© 





Fig. 58. — Hyposystolie in an arteriosclerotic; reduction of the absolute and 
relative cardiac dullness and ascension of the inferior border of the liver under 
the influence of precardial massage. (After Merklen and Heitz). 

In Fig. 58 the reduction of the hepatic dullness is shown 
following the friction of the skin ; the continuous lines show 
the superficial and the deep dullness of the heart before, and 
the interrupted lines the reduction of the areas after friction 
of the skin. 

206 



The Heart Reflex 

All physicians do not possess equal skill in determining 
the relative cardiac dullness, and I have devised a simple 
apparatus called the "Vibrosuppressor," which serves to 
simplify topographical percussion (page 80). 

The Heart Reflex of Nasal Genesis. — Reference has al- 
ready been made to the fact that the heart reflex can be 
provoked by irritation of the nasal, pharyngeal, and laryngeal 
mucous membranes, and that if the irritation is sufficiently 
prolonged and violent the movements of the heart may be 
inhibited. If the membranes in question have been previously 
cocainized the heart reflex cannot be elicited. It is evident, 
then, that previous cocainization of the nasal and pharyngeal 
mucous membranes should precede the employment of an 
anesthetic. On theoretical grounds, the laryngeal mucosa 
should not be cocainized, as it is necessary to preserve the 
laryngeal reflex to prevent the entrance of foreign substances 
into the larynx. 

The Heart Reflex of Gastric Genesis, — Knowing that 
irritation of the gastric mucosa will provoke the heart reflex, 
it is not improbable that sudden death of gastric origin may 
be caused by refljex inhibition of the heart. In instances of 
this kind the fact of a dilated stomach directly compressing 
the heart cannot be ignored. I have studied, by aid of the 
x-rays and the fluoroscope, the action of a dilated stomach 
on the heart by artificial distension of the stomach. The 
healthy heart can tolerate considerable compression and dis- 
location without modifying the intensity of the heart tones, 
but when the organ is diseased, the slightest compression 
and dislocation is followed by evil consequences. Artificial 
insufflation of the colon will also compress and dislocate the 
heart, but never in the same degree as will insufflation of 
the stomach (Fig. 33). 

The Heart Reflex of Rectal Origin, — Irritation of the 

207 



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r a p y 



rectal mucosa will also induce the heart reflex. Straining at 
stool in elderly people by increasing intraabdominal pressure, 
and thus putting a strain on the cerebral vessels, predisposes 
to rupture of the latter. Straining, however, is not wholly a 
question of pressure. Some patients, particularly those with 
weak hearts, suffer from collapse symptoms while straining 
at stool. In investigating the cause of such symptoms, I found 
that contraction of the abdominal musculature will cause 
even in the norm a veritable weak heart reflex with diminished 
■output of blood from the left ventricle. For the latter reason 
the amount of Wood is decreased in the arterial system and 



nvnkMV 



Flo. 59- — SpbygmogTam (A) before and (B) while straining al slooL 



increased in the veins. The accompanying sphygmogram 
(Fig. 59) illustrates the effects of contraction of the abdom- 
inal musculature on the heart. 

It is evident that if the heart is enfeebled the eflfects of 
such cardiac inhibition may be attended with serious results. 
It is well known that different nerves from the abdomen and 




H e a r t Reflex 

heart if the radial pulse is palpated during contraction of 
the abdominal muscles while straining at stool. 

Relative Valvular Insufficiency. — The normal heart can 
easily adapt itself to the average grades of dilatation such as 
occur during exertion ; in fact, the size of the cavities of the 
heart varies even in health, and a dilatation is physiologic 
as long as the heart cavity is capable of emptying its contents 
during systole. What is called "getting wind" in climbing 
a mountain or in athletic training is practically a moderate 
dilatation of the cavities of the right heart. In relative 
valvular insuflBciency the valves are normal, but they are no 
longer capable of completely closing the orifices of the heart. 
This condition is frequent after heart strain and involves 
particularly the tricuspid valves. A murmur which is heard 
in such instances may be made to disappear temporarily by 
inducing the heart reflex, which, by causing myocardial con- 
traction, reduces the size of the cardiac orifices, thus enabling 
the valves to close the openings. Here the excitant of the 
heart reflex must be vigorous and for this purpose the sinu- 
soidal current, with both electrodes to the precordial region, 
is most efficacious. Percussion of the precordial region with 
a percussion hammer will often suffice. 

Pericardial Effusion. — The differential diagnosis between 
a dilated heart and a pericardial effusion is often conceded 
to be a difficult clinical problem. From what has preceded 
the heart reflex can be employed in diagnosis. The reflex in 
question is absent in pericardial effusions and present in 
cardiectasis. In other words, after the heart reflex is pro- 
voked the area of deep cardiac dullness will be uninfluenced 
in effusions but modified in cardiectasis. 

It may be difficult to say whether a pulsating intra- 
thoracic mass examined with the x-rays is the heart or an 
aneurysm. A retraction of the mass after provoking the 

209 



S p ondyloth e r a p y 

heart reflex would indicate that it is the heart and not an 
aneurysm. Cooper utilized the foregoing fact in differential 
diagnosis. I will not now attempt to discuss the therapeutic 
value of the heart reflex, but it is my personal opinion that 
the carbonated baths in the Schott treatment possess no 
special effect beyond their action in provoking the heart 
reflex by cutaneous irritation and that cutaneous friction by 
any other method is equally eflicacious. The foregoing con- 
clusion is formulated only as a result of many years of obser- 
vation. Massage of the precordial region or the employment 
of the sinusoidal current, especially in cardiopaths, will 
reduce the area of the heart and the pulse-rate and augment 
blood-pressure. The now prevailing fetish in cardiothera- 
peutics is Nauheim. I subscribe equally to the efficiency and 
deficiency of this famous resort, but it is puerile to endow 
its waters with marvelous attributes. 

CARDIAC INSUFFICIENCY. 

One frequently observes in a large number of individuals 
at about the period of middle-age, definite signs of cardio- 
vascular disturbances even though no valvular lesions are 
present. Here the condition is due to some change in the 
heart-muscle which has not been definitely established even 
by the microscopist. This condition has been popularly 
designated as heart-failure or heart-weakness, and others 
speak of the condition as chronic cardiac insufliciency or 
incompetency. 

The signs of iftcampeiisatian vary according to whether they 

are caused by a lesion of the valves or occur independently 

of the latter and are dependent on changes in the myocardium. 

All diseases of the heart, whether of the valves or myocardium, 

lead eventually to disturbances of circulation. The phe- 
nomena associated with the latter are easier of interpretation 
if we study the effects of vahoilar lesions. 

210 



Cardiac Insufficiency 

The compensatory mechanism of the heart illustrates 
why cardio-vascular disease is not at once followed by dis- 
turbances in the circulation. The normal heart can easily 
adapt itself to the average grades of dilatation such as 
occur during exercise. In fact, the size of the cavities of 
the heart varies even in health, and a dilatation is physiologic 
as long as the heart-chamber is capable of emptying its 
contents during systole. Any increased work on the part 
of the heart, if continued, leads to an increase in the size 
and number of the muscle-fibers, a condition known as 
hypertrophy^ which enables the organ to contend with ad- 
ditional burdens. 

Although a valve-lesion may be of some significance in 
prognosis, yet the essential factor always is the question of 
compensation. 

Valvular lesions are of two kinds, narrowing of the valve- 
openings (stenosis), and incomplete closure of the orifices 
(incompetency or regurgitation) due to retraction of the 
valves. In either condition dilatation of one of the chambers 
of the heart occurs because it is always distended with blood, 
and incompletely discharges its contents at systole. When 
the heart hypertrophies, to overcome the latter defect, and 
thus prevents stasis in any part of the blood -current, the lesion 
is compensated. Thus compensation is practically dependent 
on the condition of the heart-muscle. If the heart fails to 
hypertrophy, or if the latter has occurred and it is subjected 
to burdens beyond its capacity, or in consequence of degen- 
erative changes, the heart fails as a motor and it becomes 
insuflScient, or, as is often said, compensation is broken or 
ruptured. In consequence of incompetence, a diminished 
quantity of blood is pumped into the arterial system, hence 
the arterial pressure is decreased, venous pressure is increased 
and the current of the blood in the capillaries is retarded. 

211 



S p n d y I t h e r a p y 



BBBBHRB 



The cavities of the ventricles dilate because they cannot 
discharge their contents (increased area of cardiac dullness). 
Overloading of the veins conduces to the collection of fluid 
in the tissues which begins primarily in the feet and gradually 
invades the other parts of the body. 

Cyanosis of the skin is an early symptom and appears as 
soon as there is a disturbance in the pulmonic circulation. 

In children, a lesion of a valve retards development and 
nutrition and produces a condition known as cardiac cachexia. 

The pulse is often characterized by intermittency and is 
caused by feeble contractions of the heart which are not 
strong enough to drive the blood to the radial artery. In 
such instances, if the heart is auscultated synchronously with 
palpation of the pulse, there are more heart-tones than 
pulse-beats. 

Dyspnea in disease of the heart is out of all proportion 
to the physical changes in the lungs and is caused by pressure 
of the enlarged heart on the lungs, disturbed pulmonic cir- 
culation, hydrothorax, ascites, or bronchial catarrh. 

Cardiac asthma may be confounded with asthma of 
bronchial origin and the following table wiU assist in difiFer- 
ential diagnosis : 

DIFFERENTIAL TABLE OF ASTHMA. 
CARDIAC ASTHMA. BRONCmAL ASTHMA. 

Signs of cardiac disease. Usually absent. 

Dyspnea is equally inspiratory and Dyspnea is expiratory, 
expiratory. 

Pulse in the early stage of parox- Pulse-tension usually increased 
ysm may be strong, but it soon throughout the paroxysm, 
becomes soft and small. 

Percussion shows an extension of Extension of lung-borders more 
the borders of the lungs and pronounced, 
obliteration of the area of super- 
ficial cardiac dullness. 

212 



Cardiac I n s u f f i c i e n c y 



CARDIAC ASTHMA. 

Auscultation shows an absence of 
rales unless complicated by lung- 
edema. 

Tracheal traction-test is positive.* 

Cardiac stimulation will inhibit 
attacks and cardiotonic medica- 
tion will prevent them. 

Tests show cardiac insufficiency 
(page 215). 



Concussion of the 7th cervical ver- 
tebra may arrest an attack at 
once by provoking the heart re- 
flex (page 199). 



BRONCHIAL ASTHMA. 

Sonorous and sibilant raXts are 
always heard and are k>udest 
during expiration. 

Tracheal traction-test, negative. 

No special results from cardiac 
stimulation. 

No cardiac insufficiency unless 
heart-weakness exists as a com- 
plication, and then the right 
heart is usually compromised. 

Very frequently the attack can be 
subdued by concussion of the 
4th and 5th cervical vertebrae 
(page 313)- 



Cardiac insufficiency due to myocardial disease may be 
divided into three main groups, which are as follows : 

I. An arrhythmic form, in which the pulse is irregular 
and intermittent and lacks force and volume. 

a. A group characterized by acceleration of the pulse 
(tachycardia) and paroxysms of palpitation. 

3. An asthmatic group, which is characterized by 
attacks of acute pulmonary edema and cardiac 
asthma. 

Usually the patients are middle-aged men of strong 
physique who have eaten to excess and have taken very little 
exercise. 

The frontier symptoms of cardiac incompetency in such 

*The author has described this test as an aid in the diagnosis of idiopathic asthma.^ ^ 
When the head of a patient is thrown forcibly backward, the normal resonance 
obtained by percussion over the manubrium sterni and lungs contiguous 
thereto becomes converted into a dull or flat sound. This manceuver is the 
tracheal traction-test. It is positive in health and in all cardiopulmonary 
affections, excepting in idiopathic asthma. In other words, in the latter 
affection, the pulmonary resonance over the manubrium is unchanged when 
the head is thrown backward. The explanation of this phenomenon is dis- 
cussed on page 311. 

213 



Spondylotherapy 

individuals are slight difficulty in breathing on exertion in 
ascending stairs and in walking up a slight hill. The in- 
dividual may observe that, after a hearty meal there is a 
feeling of uneasiness or a dull pain in the region of the 
heart. These symptoms continue to become more pronounced 
and are not infrequently associated with attacks of fluttering 
or palpitation of the heart. 

One may also observe in these cases signs of arter- 
iosclerosis. 

Percussion shows as a rule an increase in the area of 
cardiac dullness which may involve either ventricle or both. 

Respecting the prognosis in cases of cardiac insufficiency, 
it is usual to regard the cases as hopeless and that little can 
be done to patch up the crippled heart. 

The author, however, finds that provided a good heart 
reflex can be obtained, the prognosis is, as a rule, favorable- 
In this regard one may cite the observations of Heitz who 
shows that, the heart reflex of Abrams is a good guide by 
which to determine the probable efiFect of contemplated 
balneologic treatment. If the size of the heart does not 
change under the excitation of the reflex, by sharp blows 
over the precordial region, the treatment will be inefiFectual 
or may even be contra-indicated on account of the probable 
development of cyanosis. In very large dilatations and in 
advanced myocardial degeneration, the heart does not 
respond to precordial excitation and is not favorably in- 
fluenced by baths. If the reaction is feeble, good results may 
be achieved, but the treatments must be used cautiously. 
Since the author has employed concussion of the spine of 
the 7th cervical vertebra for provoking the heart reflex, 
decidedly better results can be achieved from treatment than 
by mere precordial excitation which has heretofore been 
practiced. 

214 



tl e a rt-Suffic i e n c y 

It may be remarked, that while the x-rays furnish the 
best proof of the amplitude of the heart reflex, yet results 
may be achieved by percussion, if the vihrosuppressor is 
employed as an aid (page 80). Here one percusses the 
heart to obtain the deep or relative cardiac dullness and the 
limitations of the organ are carefully marked with a pencil. 
Next, one rubs vigorously the skin over the region of the 
heart, or, better still, one strikes a series of concussion -blows 
upon the spinous process of the 7th cervical vertebra and 
percussion of the heart is again executed ; any diminution in 
the area of cardiac dullness indicates the amplitude of the 
heart reflex. 

TESTS FOR HEART-SUFFICIENCY. 

In disease of an organ, the severity of a lesion is generally 
gauged by the incapacity of the organ to execute its functions. 
Thus it is, that in affections of the kidney, the percentage 
of albumin in the urine is of minor prognostic importance, 
provided the nitrogenous excretion is relatively normal. 

Similarly, in affections of the heart, a murmur is of no 
value in determining the prognosis of any given case, inso- 
much as some of the most serious affections of the heart are 
unaccompanied by murmurs. 

In the presence of a cardiac disease, whether of the valves 
or of the muscle of the heart (myocardium), it should be 
the primary endeavor of the physician to determine the 
functional capacity of the organ. Many functional diseases 
of the heart, described as cardiac neuroses are mere instances 
of heart-fatigue, for the heart like the skeletal muscles will 
tire when an additional burden is cast upon it; in fact, the 
heart may be the most vulnerable muscle in exhaustion. 

We have already noted (page 203 ) the effects of emotions 
on the heart and among neurasthenics, emotional influences 

215 



must be regarded as additional etiologic factore in super- 
inducing heart -fatigue. 

There are many individuals, notably women, labeled as 
neurasthenics, who are really sufferers from cardiac Jncom- 
pensation. 

To determine the vigor of the myocardium, the conven- 
tional physical methods of examination furnish little practical 
aid, hence recourse is had to any of the following manoeuver^ : 

1. The pulse method.— The pulse of the cardiopath 
is altered in character after body-movements and physical 
exertion in a more pronounced manner than in health, and 
such alteration is in proportion to the insufficiency of the 
heart-muscle. When the heart is healthy and one counts 
the pulse first in the erect and again in the recumbent 
posture, a retardation of the pulse in the latter position from 
lo to 12 beats per minute is obser\-ed. In disease of the 
heart -muscle, however, retardation of the pulse in the 
recumbent posture becomes less and less conspicuous, the 
greater the degree of cardiac insufficiency, until in pro- 
nounced grades of the latter, the frequency of the pulse 
may even be greater in the recumbent than in the erect 
posture. 

2. Blood-pressure method. — This method (like the 
two following methods) requires the use of a blood -pressure 
instrument (sphygmomanometer, page 244). It is known 
that muscular work is associated with alterations in the 
arterial blood -pressure. In health muscular exertion in- 
creases the blood -pressure, but, if the heart is insufficient, 
this rule is reversed, viz., muscular exertion will reduce the 
blood -pressure. The less evident the rise in pressure after 
exercising the muscles, and the deeper the remissions of the 
blood-pressure curve and the less muscular exercise it takes 
to produce such remissions of pressure, and the longer it 

216 



He a rt'Suffic i e n c y 

takes for the blood-pressure curve to attain the normal, the 
greater is the functional incapacity of the heart. 

3. Method of katzenstein. — ^After determining the 
blood-pressure and the pulse on the reclining patient, both 
of the femoral arteries are compressed with the middle 
finger of each hand at Poupart's ligament, the other 
fingers testing whether the compression is absolute. With 
normal heart-energy the blood-pressure then rises by from 
5 to 15 mm. mercury, while the pulse remains unaflFected or 
drops. When the compression is relinquished, the blood- 
pressure gradually returns to normal. A slightly enfeebled 
heart is not able to raise the blood -pressure when the ob- 
struction to the circulation is interposed, and with a much 
enfeebled heart the blood-pressure actually sinks under the 
compression, while in both events the pulse becomes more 
or less accelerated. The respiration is kept superficial during 
compression. 

4. Heart reflex method. — ^After taking the blood- 
pressure, fix over the heart-region a pleximeter and strike 
the latter a series of vigorous blows with a hanmier (Fig. 2), 
after which immediately take the pressure again. If the 
myocardium is sufficient, the blood-pressure remains the 
same or rises ; otherwise, it falls, and the rise and fall are in 
proportion respectively to the vigor and insufficiency of the 
heart-muscle, e.g.: 

BLOOD-PRESSURE BEFORE AND AFTER EXCITATION OF THE 

HEART-REGION. 
BEFORE. AFTER. CONCLUSION. 

120 mm 140 mm Myocardium very. strong. 

135 mm 138 mm Myocardial sufficiency. 

190 mm 155 mm Myocardial insufficiency. 

Concussion of the heart region elicits a maximum heart 
reflex with a temporary augmentation of vigor if the myocar- 

217 



S p n d y I t h e r a p y 

dium is normal, otherwise, the stimulation is in the nature 
of a shock. 

TREATMENT OF CARDIAC INSUFFICIENCY. 

One must concede the phenomenal results achieved in 
cardiotherapeutics since the inauguration of the Schott 
methods by saline baths and resisted movements in failing 
heart-power. If the Schott methods of treatment are 
eflFective, their efficiency is recognized by the following 
results : 

1. A sensation of warmth. 

2. Augmented pulse- volume with diminished frequency. 

3. Stronger cardiac systole. 

4. Diminished area of cardiac dullness. 

5. Amelioration of precordial distress. 

6. A feeling of well-being. 

There are many theories concerning the action of the 
saline baths and resisted movements, but in the opinion of 
the author, the theory that best responds to reason is that 
which supposes their action to be due to the elicitation of 
the heart reflex. From what has been said concerning the 
latter reflex (page 199), it is known that cutaneous stimulation 
of any kind will result in a vigorous contraction of the 
heart-muscle. Hence, mere friction of the skin with a coarse 
towel is equally as efficient as the waters of Bad Nauheim, 
in Germany, which owe their action to various chlorid salts 
and to the presence of carbonic acid.* 

In studying the amplitude of the heart reflex (Fig. 54), 
when elicited from various regions of the organism, the 

*"Dr. Bloch, of Franzensbad, uses carbonic acid douches for producing contraction 
of the heart, based on the fact discovered by Dr. Abrams, of San Francisco, 
that friction of the precordial region will produce contraction of the heart 
(Satterthwaite)." 

218 



Cardiac I n s u f f i c i e n c y 

author is justified in concluding that the most eflFective site 
is the spinous process of the jth cervical vertebra, and that 
the most satisfactory method for its elicitation, is by means 
of the pneumatic hammer (Fig. 50) or any similar apparatus 
giving a percussion stroke. In the absence of an apparatus, 
mere concussion by means of a pleximeter and hammer 
(page 8) may be employed. 

The duration of each s&mce is governed by the results 
and one must not forget that a reflex may be exhausted as 
well as excited. My usual custom is to limit each stance to 
about five minutes with frequent periods of rest during the 
application of the percussion stroke. In the opinion of the 
author, the results achieved are more satisfactory and more 
rapid than by any other method of treatment. 

Very frequently he has observed cardiopaths with severe 
dyspnea and other signs of heart failure, who obtained 
immediate relief after a single stance of concussion -treat- 
ment. 

It is evident, however, that many stances are necessary 
before one may expect permanent results. 

It is equally evident that concussion must not be em- 
ployed to the exclusion of other methods of treatment 
in failing compensation, although the author has employed 
concussion exclusively in his cases to enable him to formulate 
conclusions respecting the efficacy of the method. 

Reference to Figs. 60 and 61 shows the effects of con- 
cussion of the 7th cervical spinous process in two patients 
with dilated hearts superinduced by myocarditis. The relief 
following concussion is dependent on the duration of the 
heart reflex which, in turn, is dependent on the condition of 
the heart-muscle. In several instances of myocarditis no 
results were achieved by concussion, but in these cases the 
myocardimn was past restitution. 

219 



S p 



d 



I 



t h 



r a p y 



Wicn attacks of cardiac asthma (page 212) or other 
paroxysmal symptoms of heart-failure occur at the home of 
the patient, some competent member of the family is instruct- 
ed to concuss the spinous process of the 7th cervical vertebra 

by means of the plcximeter and hammer. 




Fig. 60. — The effects of concussion 
of the spine of the ;ih cervical vertebra 
on the area o( the heart in a patient 
with myocarditis. The conlinuoua line 
represents the area of ihe heart before, 
and the broken line after, concussion. 



FiC. 61.— The effects of concussion 
of the spine of the 7th cen'ical lenetjm 
on the area of the heart and liver in a 
patient with advanced myocarditis. The 
continuous line represents the area of 
the heart and liver before, and the 
broken line after, c 



As a rule, the latter manoeuver is followed by immediate 
relief of the symptoms. 

As observed on a previous page (215), some patients 
owe their infirmity to heart-failure and many anemic women 
who respond unceasingly to the demands of an active social 
life, who say they are "worn out," often suffer from an over- 
strained heart. The subjective symptoms are lassitude, 
slight dyspnea on exertion and digestive disturbances. 



Angina Pectoris 

*-^'— —————— —■^■^— — — i^— — — 

Objectively, one may recognize dilatation of the ventricles 
by percussion, feeble heart-tones, and a pulse which is rapid 
and feeble and may be irregular or intermittent. These 
cases, as well as those hearts which fail to respond to the 
tests of cardiac sufficiency (page 215) are benefited by 
concussion-treatment. 

ANGINA PECTORIS. 
THE HEART REFLEX OF DILATATION. 

Heretofore only one heart reflex was recognized, viz.^ 
the heart reflex of contraction (page 199), but when the 
ipnial processes of the 9th, loth, nth and 12th dorsal 
^Cft ebrc are rapidly concussed in succession there is a 
decided increase in the area of cardiac dullness as obtained 
tjr percussion. This increase in the area of cardiac dullness 
» not associated, as the x-rays show, with any increase in 
&e diameters of the heart. The latter fact corresponds with 
the investigations of Komfeld, who demonstrated that the 
heart-muscle possesses the property of increasing the size of 
its cavities without any corresponding augmentation of 
tension of its walls, a condition which he calls Ausweitungs- 
fdhigkeil. 

Among the theories of angina pectoris, that of Allan 
Bums appeals most cogently to reason. 

The latter assumes that, in consequence of a transient 
ischemia of the heart -muscle caused by disease or spasm of 
the coronary arteries, a condition analogous to intermittent 
claudication ensues. It is known that the coronary arteries 
are practically always diseased in fatal cases of angina, but 
if we accept the observation of Schafer that the coronary 
vessels are unprovided with vasomotor nerves, the theory of 
intermittent claudication of the coronaries must necessarily 
suffer a serious setback unless supported by other evidence. 

221 



S p ndylotherapy 

The coronary arteries supply the heart with blood only during 
diastole, for during systole the ventricular wall is so strongly 
contracted that the muscular tension becomes greater than 
the coronary pressure and so the coronary artery and 
branches are compressed and the blood is driven back into 
the aorta. It is our contention that the theory of Bums 
is correct, but that the ischemia is quite independent of 
the coronary arteries, which are merely passive structures. 
We assume that any factor operating to augment the 
tonicity of the cardiac musculature compresses the arteries 
in question and thus induces ischemia. The heart reflex 
is essentially a myocardial contraction and when the 
reflex is in evidence the coronary arteries are subjected 
to varying degrees of pressure. If in an attack of angina, 
the pulse shows augmented tension and is small and perhaps 
diminished in rate, or if syncope is observed, such symptoms 
are explainable by the heart reflex. 

We know that when the reflex is in evidence, the heart is 
practically inhibited ; there is a diminished output of blood 
into the general circulation and, if the pulse shows increased 
tension, it is only an expression of vaso-motor activity which 
assumes the burden of maintaining the circulation. 

If one studies the etiology of angina, one notes that the 
factors which precipitate a paroxysm are also equally 
operative in inducing the heart reflex. Muscular effort is a 
potent factor which also provokes the myopathic heart reflex. 
Emotion is another prominent factor and led John Hunter to 
observe that "his life was in the hands of any rascal who 
chose to annoy and tease him." Emotion as a cause corre- 
sponds with the psychic Jieart reflex. A gust of wind striking 
the chest is equally involved in inducing either an attack of 
angina or the heart reflex. 

Oliver demonstrated that patients who have suffered from 

222 



ji n g i n a Pectoris 

precordial pain obtain permanent relief on the supervention 
of cardiac dilatation and failure, and Broadbent has shown 
that the supervention of mitral insuflficiency may diminish 
the tendency to anginoid attacks. 

Now, in cardiectasis, while the heart reflex can be 
provoked, the cardiac musculature is enfeebled and the 
resulting pressure on the coronary arteries is correspondingly 
diminished. Reference has been made to the heart reflex of 
dilatation and in several instances, during my office hours, 
I have inhibited anginoid pains by concussion of the vertebrae 
which induces cardiac dilatation, and I have employed the 
same method with fairly good results in the treatment of 
angina pectoris. In other instances, I have unintentionally 
provoked attacks of angina in studying the heart reflex and 
the methods for its elicitation. 

Here concussion of the spinous process of the 7th cervical 
vertebra is often effective in developing some of the symptoms 
of angina pectoris when absent and the same may be said 
of concussion of the precordial region. Thus, concussion 
from either region is a diagnostic sign of some importance 
and serves as corroborative evidence of the author's heart 
reflex theory of angina pectoris. Not infrequently eructa- 
tions of gas attend the concussion and here it is assumed, 
that concussion not only provokes the heart reflex by reflex 
stimulation of the vagus, but also the stomach reflex of 
contraction (page 316). 

By means of the heart reflex, one can easily comprehend 
the attacks of false angina. In functional angina, the heart 
reflex is always accentuated, as I have assured myself by 
repeated x-ray examinations. In cardiodynia (Herzangst) 
observed in neurotics, one is dealing essentially with a 
psychic heart reflex. 

The following table will aid in the differentiation of true 
and false angina pectoris : 



S p 



n 



t h e r a p y 



DIFFERENTIAL TABLE OF TRUE 
TRUE ANGINA. 

Most frequent between the ages of 
40 and 50 years. 

More frequent in males and the 
paroxysms are evoked by exer- 
tion. The attacks are rarely 
periodic and nocturnal. 

No other symptoms. 

Pain is agonizing with the sensa- 
tion of compression by a vice. 

The pain is of short duration and 
the patient is silent and immo- 
bile. 

The lesion is a sclerosis of the 
coronary artery. 

Prognosis grave. 

Arterial medication is eflfective. 
Antipyrin (large dose) may ac- 
centuate the pain, at any rate it 
gives no relief. 



AND FALSE ANGINA PECTORIS. 
FALSE ANGINA.* 

(Neurotic Form.) 

May occur at any age and even 
in children. 

More frequent in women and the 
attacks are spontaneous, peri- 
odic and nocturnal. 

Associated with nervous symfH 
toms. 

Pain is less severe and the sensa- 
tion is one of distention. 

Pain may continue for one or two 
hours and the patient is restless 
and talkative. 

Neuralgia of nerves and cardio- 
plexus. 

Never fatal. 

Antineuralgic medication. Anti- 
pyrin (large dose) is eflfective in 
subduing the pain (Huchard). 



There are etiological factors concerned in angina which 
on first view could find no explanation by my heart reflex 
ischemic theory, yet, on reflection, the theory is applicable. 
Thus, one of my friends, a physician in Paris, suffers like 
several other members of his family from pronounced attacks 
of angina pectoris several hours after the use of coffee, tea 
or tobacco. One knows, for instance, that the effect of 
caffeine in small doses on the cardiac muscle is to increase 
its activity ; in larger doses, it produces phenomena analogous 
to fatigue, and in very large doses, the muscle is thrown into 

♦Reference on page 194 has already been made to false angina caused by intercostal 
neuralgia. 

224 



A n g 



n a 



c t 



SB 



rigor. In the latter instance, the strong contraction of the 
myocardium (which is essentially a heart reflex) mechanically 
compresses the coronary vessels. 

The toxic factor here involved in eliciting the heart reflex 
is necessarily delayed and cannot be immediate like the other 
factors concerned in the elicitation of the reflex in question. 
Digitalis and other circulatory stimulants may provoke an 
attack of angina for the reason that they augment the tonicity 





Fig. 62. — ^The heart reflex; A before, and B, after, the use of digitalis. 

of the cardiac musculature. Digitalis increases the ampli- 
tude of the heart reflex as shown in Fig. 62. 

Recently I have observed the following singular phenom- 
enon : After placing the ankle of one lower extremity on the 
knee of the other extremity, the pulse of the anterior tibial 
artery is easily palpated (Fig. 63). 

Next, direct the patient forcibly to extend and flex his 
foot (the leg occupying the same position) a number of 

225 



S p n d J I 



1 h 



P 3 



tiroes in ^ucces^jn. If the libizl poke is ^un soi^ht, it 
wiU be either i-ety {eeble or abwnt. In tlie oonn fidljtlm^ 
xconls may elapse before tbe plibe has attained ite ionaa 
voiume. The blood -pressure ako bOs. In a paoent iri& 
daudicatton, five mtnutes dapsed befbte liie tibial pulse 
resomtd its finmer itrfutDe. This test mar prove oC value 
in the diagnosis of tbe latter affectioo. I assume that the 
tibial arter}', iminer^ as it is in a nnisnihr atmoq^iere, 
responds rtrtlcxlj to the muscular ooaliactians, and in artc- 




Vm. 6,1.— I'o«ll[oo ot ihe leg to facilitate palpation of the 



riosclcrosis the longer duration of the arterial contraction 
accounts for the i)licnoniena of claudication. Here, as in 
my heart reflex theory of angina, the ischemia is dissociated 
willi vaso-motor action, insomuch as when amy] nitrite is 
inhaled, obliteration of the tibial artery is effected by the 
muscular manocuver suggested. 

The treatment of angina pectoris includes the elimination 

of all factors concerned in the elicitation of the heart reflex. 

The value of timyl nitrite inhalation in the treatment ol 

226 



of^_ 



ji n g i n a 

paroxysm is universally conceded. When the latter drug 
fails, and it often does, the failure may be attributed to 
irritation of the nasal mucosa which induces the heart reflex, 
which would still further accentuate the paroxysm. In such 
instances and, in fact, in nearly all instances, the action of 
the drug in question is aided by previous cocainization of 
the nasal mucosa, which eliminates the irritant factor in 
amyl nitrite inhalations. Concussion of the lower dorsal 




Fig. 64. — Demonstrating the amplitude of the heart reflex: C, left border of 
the deep cardiac dullness; A, recession of the same border when the heart reflex 
is elicited after excitation of the precordial region; B, still further recession of the 
same border when the heart reflex is elicited after concussion of the spinous proc- 
ess of the 7th cervical vertebra. Note in this figure that after concussion of the 
four lower dorsal vertebrae to excite the heart reflex of dilatation, the amplitude 
of the heart reflex of contraction after concussing the spinous process of the 7th 
cervical vertebra is from C to A only. 

vertebrae (daily treatment) should be given a trial in the 
treatment of angina pectoris to induce the counter-reflex of 
dilatation. 

It will be noted in Fig. 64, that after the heart reflex of 
dilatation is elicited, the amplitude of the heart reflex of 
contraction is diminished. In some instances, the treat- 
ment suggested for angina pectoris (true and false) and 

227 



Spondylo the r , 

cardiodynia is very effective, whereas in other instances, nO' 

results are achieved. 

FUNCTIONAL AFFECTIONS OF THE HEART. 

INHIBITION OF THE HEART, 

The rapidity and force of cardiac action are regulated by 

the pneumogastric or vagus nerve, which inhibits it. and the 




sympathetic, which accelerates it. Many persons can volun- 
tarily stop the action of the heart, and among Indian 
sorcerers, the phenomenon is regarded as a marvelous feat. 
The explanation, however, is very simple: by voluntary 
contraction of the muscles of the neck innervated bv the 



H e a r t - Inhibition 

nervus accessorius, the' branches of the latter running in the 
path of the vagus nerve are irritated, resulting in temporary 
stoppage of the heart action. Czermak was able to press 
his vagus nerve against a little bony tumor in the neck, and 
by thus subjecting the nerve to mechanic stimulation was 
able to slow or even stop the beating of his own heart. 

If, in almost any healthy person, the carotid artery, or a 
point inmiediately adjacent to it in the neck, is compressed, 
slowing or complete inhibition of the heart and pulse ensues. 
This phenomenon is explained by compression of the vagus 
lying alongside the carotid artery. 

The author has shown, that forcible compression of the 
abdominal muscles (Fig. 59), inhalation of irritating vapors, 
firm pressure in any of the intercostal spaces and pressure 
at the vertebral exits of the spinal nerves (preferably at 
the side of the upper dorsal vertebrae, Fig. 48), will 
result in a reflex inhibition of the heart. A method which 
the author employs for this purpose is to have the patient 
firmly contract the muscles of the neck as shown in Fig. 65. 

There are many functional neuroses of the heart, 
such as palpitation, arrhythmia and tachycardia, which owe 
their origin to insufficiency of the vagus nerve, and in con- 
sequence of such incompetency, the mastery of the organ is 
assumed by the sympathetic. 

Now we know that the action of the vagus can be reflexly 
controlled by the manoeuvers already cited, and in this 
action, acceleration and irregularity of the heart can be 
mastered. By executing such a manoeuver, we are merely 
subduing one reflex by its counter-reflex. 

In a case of tachycardia (heart-hurry) reported by 
Nothnagel, the attacks were jugulated by deep inspirations, 
and Rosenfeld's patient controlled her attack by going to 
bed, raising her head with her feet planted firmly against 

229 



S p n d ylotherap'j 

the foot of the couch, and then taking a forced inspiration 
she pressed down with all her might, with the object of 
closing her glottis. 

A patient of mine, a neurasthenic, controlled his attacks 
of palpitation by firm compression of an intercostal space 
with his finger. 

An analysis of the foregoing manoeuvers, acquired 
instinctively, shows that what the patients did was to call 
into action the functions of the vagus nerve. 

The spinal region in juxtaposition to the vertebral exits 
of the upper spinal nerves (at about the spinous process of 
the 4th dorsal vertebra), is the most favorable site for calling 
into activity the functions of the inhibitory nerve of the heart. 
Here the most suitable method is to make firm compression 
(and maintain the compression for several minutes) with the 
thumbs on either side of the spine. 

The application of an ice-bag in the region shown in 
Fig. 48 (corresponding to 7th cervical spine) is often of 
service and the same may be said of the sinusoidal current; 
one electrode in the sacral region and the other electrode 
in the region indicated in Fig. 48. In arrhythmia, the 
action of this current is often surprisingly efficient. 

The latter manoeuver is equally available in diagnosis. 
Thus, in irregular action of the heart or in delirium cordis, 
the inhibition manoeuver, by temporarily inhibiting the 
rapidity of the heart, enables us to determine the time of a 
murmur; the manoeuver thus simulating the physiologic 
action of digitalis.* 



of the Heart " h ^!^|f "^P^^y'^c'^t of this manoeuver in diagnosis, vide ''Diseases 
. oy the author, page 59. 



230 



^ h e Blood-Vessels 



BB 



THE BLOOD-VESSELS. 
PHYSIOLOGY. 

The blood -pressure is most evident in the arteries and 

least pronounced in the veins, whereas in the capillaries, it 

is intermediate between the arteries and veins. Thus the 

hlood circulates continuously in the direction of the lowest 

pressure (arteries to veins). 

Arterial pressure or tension is made up of four factors : 

I. Ventricular pressure. 

3. Peripheral resistance. 

3. Elasticity of the arterial walls. 

4. The volume of the circulating blood. 

Innervation of the blood-vessels is effected through the 
vaso-motor nervous system, which consists of the center in 
the bulb, subsidiary centers in the spinal cord and vaso-motor 
nerves. 

The latter are of two kinds : Vasoconstrictor nerves, which 
when stimulated cause contraction of the vessels, and vaso- 
dilator nerves, which dilate the vessels. The latter supply 
the musculature of the vessels and regulate their caliber, and 
their most pronounced action is on the arterioles, which 
contain relatively the largest amount of muscular tissue. In 
the norm, the arterioles are in a state of tonic contraction, 
and this is what constitutes the peripheral resistance which 
helps to maintain the blood -pressure and thus promotes the 
circulation of the blood. By means of the vaso-motor 
apparatus the amount of blood supplied to an organ is regu- 
lated. Thus, during digestion more blood must be supplied 
to the digestive organs, hence the arterioles of the splanchnic 
area are relaxed and there is a constriction of the vessels in 
other areas, as, for example, the skin ; the chilly sensations 
after a meal are attributable to the latter fact. In certain 

231 



Spondylotherapy 



BBBBI 



organs, like the lung and brain, there are no vaso-motor 
nerves, because there are no variations in the blood-supply. 
There are afferent impulses which may reflexly excite the 
vaso-motor center in the medulla, and such impulses are 
divided into pressor and depressor. Most sensory nerves 
contain pressor fibers which, when stimulated, cause a rise 
of blood -pressure, whereas the depressor fibers also present 
in many sensory nerves will, when stimulated, cause a fall 
of blood -pressure. A distinct nerve known as the depressor 
nerve exists in animals in the trunk of the vagus, or as a 
separate branch running from the heart or the conunence- 
ment of the aorta, and reaches the vaso-motor center by 
joining the vagus. 

PATHOLOGIC PHYSIOLOGY. 

The primary factor in blood -pressure is the force of 
ventricular systole, and any increase in the voliune-output 
causes a rise, and conversely a fall, in pressure, provided 
the peripheral resistance is the same. In animals the pulse- 
rate is slowed when the arterial pressure is raised and 
accelerated when lowered. A continued high blood -pressure 
entails increased work on the part of the heart, but the 
abnormal tension of the ventricular wall stimulates the fila- 
ments of the depressor nerve and thus automatically causes 
a fall of pressure. Another protective mechanism exists to 
prevent excessive blood -pressure, and that is, when the 
peripheral resistance is very much augmented, the volume- 
output of the ventricle diminishes. Peripheral resistance^ as 
has been noted, is made up of the tonus of the arterioles, 
but there are minor factors also concerned, notably, friction 
due to the viscosity of the blood and the subdivisions of the 
arterial tree. It has been shown that the veins also possess 
tonus. Thus, stimulation of a splanchnic nerve will produce 
a contraction of the portal vein. The vasodilator have not 

232 



Blood - rressure 

the same physiologic value as the constrictor nerves, for 
their division causes no narrowing of the vessel, hence they 
possess no tonus. It has been shown that stimulation of 
the muscles and the mucosa of the rectum and vagina will 
cause a fall of blood-pressure, and this fact is more evident 
during anesthesia. In the latter instance depressor in lieu 
of pressor reflexes occur. The abdominal vessels supplied 
by the splanchnic nerves have the most pronounced influence 
on the general blood -pressure, for the evident reason that 
they are sufficiently capacious to hold practically all the 
blood -voliune of the body. Arterial elasticity diminishes the 
work of the heart. Hasebroek contends that there is a pro- 
pulsive energy at the periphery independent of that in the 
heart, and that the periphery represents another second 
independent pumping apparatus, coupled with that of the 
heart. The periphery has not only its elastic contraction and 
expansion, but also its active diastole and systole in the 
arteries. This diastolic -systolic activity is manifested in the 
capillaries as a sucking-in, an inspiration, as it were, while 
in the arteries it is more of a propulsive energy. Both 
these forces combine to create an independent and forcible 
stream into the veins, which are passive, and merely serve 
as a passive reservoir for the blood -stream. 

The blood-volume has only a subordinate influence on 
blood -pressure, as many experiments show. When the 
blood-volume is diminished, pressure is maintained by 
peripheral contraction of the arterioles, and when the volume 
is increased, certain compensatory mechanisms come into 
play, viz., dilatation of the vessels, transudation into serous 
cavities and lymph -spaces, and increased activity of the 
secreting organs. Another important factor in compensation 
is dilatation of the arterioles of the abdominal viscera caused 
by stimulation of the depressor nerve. 

233 



Spondylotherapy 

Normal blood -pressure. — Pressure, like temperature 
and the rate of respiration, is subject to fluctuations. Most 
of the recorded results have been obtained with the Rvoa- 
Rocci apparatus and the figures quoted represent the systolic 
pressure. Cook and Briggs present the following as repre- 
senting the average pressure : 

Children up to two years 75 to 90 mm. 

Children after two years 90 to 1 10 mm. 

Young adult males, about 130 mm. 

Women 10 to 15 mm. lower. 

A pressure below 70 mm. signifies very low, and above 
200 mm. very high tension. 

Jane way has never seen a pressure above 180 nun. in a 
normal person, and seldom one above 160 mm. There are 
postural variations of pressure, hence all pressure estimations 
should be taken in the same position. Sleep lowers the 
pressure. Tobacco either increases or diminishes the pres- 
sure according to whether the subject experiences a stimu- 
lating or sedative effect ; this, at least, has been my observa- 
tion. Emotional influences and intellectual application in- 
crease the pressure. Muscular exertion increases the pressure, 
owing to augmented ventricular force ; if, however, exertion 
is carried to exhaustion, the pressure falls. 

BLOOD -PRESSURE IN DISEASE. 

Among the dominant factors inducing high pressure 
(hypertension) are pains of all kinds which reflexly cause a 
stimulation of vaso-motor tone. Drugs like strychnin, digitalis, 
adrenalin, and other cardiotonics act by increasing either 
the peripheral resistance (vasoconstriction) or cardiac energy 
or both. Vasoconstriction is evoked by many toxic conditions 
(plumbism, nicotinism, gout, uremia). No doubt a toxic 

234 



Blood- P 



u 



factor is also present in many psychoses. During labor 
pains two factors are present, the pain and the increased 
volume of blood sent to the heart by compression of the 
abdominal vessels. In refud affections the cause of high 
pressure is due to a number of conditions, notably, cardiac 
h)rpertrophy and increased peripheral resistance due to a 
vaso-motor spasm provoked by the irritating action of waste- 
products in the blood or degeneration of the peripheral 
vessels or both. Hypertension necessarily increases the work 
of the heart unless a compensatory factor is brought into 
play, and the primary effect is to cause cardiac hypertrophy. 
A hypertrophic heart is by no means as good as a normal 
one, as the old dictum runs, for, sooner or later, that heart 
will become insufficient. Hypertension diminishes the elastic 
distensibility of the arterial wall, and this in turn conduces 
to dilatation (aneurism) and rupture (cerebral hemorrhage) 
of the vessels. Diminished pressure {hypotension) is 
usually regarded as such when the systolic pressure in an 
adult is below loo nun. Any or all of the factors concerned 
in blood -pressure may be involved ; wasting diseases reduce 
pressure by compromising all these factors. The vasodi- 
lators reduce pressure by diminishing the peripheral resist- 
ance and chloroform acts by directly paralyzing the vaso- 
motor center or heart. In acute infectious diseases the fall 
in pressure is due in part to vaso-motor paralysis and in part 
to weakness of the heart-muscle. Hypotension causes blood 
to accumulate in the veins (notably the abdominal) and 
diminishes the rapidity of the circulation. The vigor of the 
heart becomes compromised because it receives less blood. 

In affections of the nervous system Pal found that in 
tabes, during the occurrence of lightning pains, the pressure 
fell, and that during gastric and abdominal crises there was 
an enormous augmentation of pressure, hence he concludes 

235 



Spondylotherapy 

IBB^^BI^EBBaBB^8^BBaB^aBBaB^^^B^BaBi^BSaaEBS^=aS&SaB:BSBSS=^B^ 

that the latter are caused by a spasm . of the splanchnic 
vessels. Cerebral hemorrhagey like all other conditions in- 
creasing intracranial tension, will cause an increase of 
pressure in proportion to the degree of such tension. A high 
and rising pressure points to more bleeding and a progressive 
failure of the circulation in the medulla. The observations 
of Bruce show that in insomnia there are cases with high 
and low pressure, and that the administration of erythrol 
tetranitrate to the former acted as a hypnotic (if it reduced 
tension). 

In arteriosclerosis (which will be discussed later at great 
length), the pressure is usually high. 

The arteries may be thickened and yet no rise of pressure 
exists ; in fact, if the heart-muscle is weak, the pressure may 
even be lower than normal. Janeway concludes that high 
pressure in this disease indicates involvement of the small 
arteries, especially in the splanchnic circulation. Among 
the symptoms of arteriosclerosis are headache, vertigo, 
apoplectiform attacks, and irritability. Such symptoms are 
accentuated when the pressure is high, and are aggravated 
by raising the latter with subcutaneous injections of adrenalin 
and ameliorated by the use of vasodilators. Amyl nitrite 
inhalation may be tried to rapidly secure the latter 
action. 

Sphygmomanometry has been utilized in tracing the 
etiology of insomnia. Thus, it is claimed that when the 
latter is caused by auto-intoxication, the blood -pressure is 
augmented, whereas it is very low in the insomnia of neu- 
rasthenia. 

Marfan contends that arterial hypotension is the rule in 
chronic puhnonary tubcrculosiSy and that a normal or increased 
pressure indicates a favorable prognosis. When the tension 
at the commencement of the treatment is low, and is subse- 

236 



Blood - Pressure 



B^BBBaBBBaBaBasaBBBB^BB^BBH^BH 



quently raised, the prognosis is equally favorable. Inversely, 
a constant low pressure portends an unfavorable course. 

In the differential diagnosis between gouty and tuber- 
culous affections of the skin or elsewhere, a high pressure 
argues in favor of the former and a low pressure in favor of 
the latter affection. Albuminuria is probably of renal 
origin if the pressure is high. In neurasthenia due to 
intestinal auto-intoxication the pressure is usually high, and 
treatment addressed to the condition will lower the pressure, 
whereas in neurasthenia due to actual exhaustion, the pres- 
sure is low. 

In high blood -pressure due to augmented tonus of the 
vaso-motor center (usually present in neurasthenic conditions ) 
the bromids carried to their physiologic effects will cause 
such pressure to fall. When dependent on the absorption of 
enterotoxins, the abdominal application of the sinusoidal 
current for a week (daily stances of fifteen minutes) will 
cause a marked reduction in blood -pressure, otherwise the 
influence of the current is without pronounced effect. Amyl 
nitrite inhalations and nitrogylcerin are transitory in their 
action in reducing pressure. Cook found that sodium 
nitrite is less transitory in its action, and that one or two 
grains averages a fall of from 25 to 50 mm. Hg, coming on 
rapidly in from five to ten minutes on an empty stomach, 
and its effects may last as long as four hours. Veratrum 
viride is more permanent in its effects for vasodilation than 
the other remedies mentioned. 

The testimony of clinicians concerning pressure -figures in 
diseases of the heart are very conflicting, and I must there- 
fore still adhere to my observations concerning this subject, 
and referred to elsewhere (page 239). 

Janeway regards pressure as a means of differentiation 
between true and false angina, and observes that in the pres- 

237 



S P 



t h 



r a p y 



ence of a pressure above i8o mm. anginoid pain is dependent 
on organic disease. In chronic interstitial nephritis high 
pressure is an early and important symptom. In other renal 
affections the question of pressure is less important. Uremic 
symptoms cause a rise in pressure, and that improvement 
spontaneous or as a result of treatment will cause the pressure 
to fall. In fact, many writers claim that uremic symptoms 
(headache, vertigo, etc.) are the result of high pressure. 

In typhoid fever observations to be of any value must be 
made daily with the sphygmomanometer, just as one makes 
the record of the pulse and temperature. In this disease 
the pressure begins to fall with the development of toxemic 
symptoms, and one notes that this fall is progressive. The 
following figures of Crile are interesting: The highest 
pressure in 115 cases was 138 mm.; the lowest, 74 mm.; and 
the average, 104 mm. The average pressure in the first 
weekof the disease was it's mm. ; second, 106 mm.; third, 102 
mm. ; fourth, 96 mm. ; and in the fifth week, 98 mm. A rapid 
fall in pressure indicates hemorrhage, whereas a progressive 
fall suggests enfeeblement of the vaso-motor centers. If per- 
foration occurs, there is usually a sudden rise of pressure. 
The fall of pressure in this disease suggests the value of 
cardiotonic medication, which in most instances is of more 
vjilue than the measures employed for reducing the 
temperature. 



B I 



u r e 



diseased cerebral arteries, the result of a sudden increase of 
pressure. Hemorrhage in an anesthetized patient causes a 
sudden fall of pressure followed by a rise, provided the 
bleeding is not severe or complicated by shock. In collapse 
and shock a fall of blood -pressure is one of the most positive 
signs, and the fall is always in proportion to their severity. 
According to Crile, collapse is a sudden shock, a progressive 
fall of pressure, and in which the vaso-motor center does not 
respond to stimuli. In these cases the danger exists in loss 
of the vaso-motor and not of the cardiac function. The use 
of chloroform is interdicted when shock is feared and pe- 
ripheral stimuli are inhibited by "blocking" large nerves by 
means of cocain before their division. Bishop has directed 
attention to a constitutional condition of low arterial tension 
in children in whom no heart lesion exists. Such children 
sufiFer discomfort for lack of circulation (cold feet, depression 
and fainting attacks). The functional heart-tests show that 
the heart is not compromised. Otis, of Boston, suggests 
that blood -pressure should be taken as a routine measure. 
The average blood -pressure in tuberculous persons is about 
126, and a fall in tension is suggestive of impending hem- 
orrhage. This latter may be warded off by ergot. In 
hemorrhage when the blood -pressure for the individual is 
high, inhalations of amyl nitrite or nitroglycerin may be 
used internally ; if low, ergotin is injected subcutaneously. 

THE VASO-MOTOR FACTOR IN BLOOD-PRESSURE. 

Among the factors which contribute to blood -pressure, 
the resistance offered by the blood-vessels is paramount. 

If the vessels are dilated, the pressure falls ; if contracted, 
it will rise. The nervous mechanism which presides over 
the tonus of the blood-vessels is the vaso-motor apparatus, 
and while the latter, I concede, may be reflexly influenced 

239 



S p 



r a p y 



by irritation from the blood-vessels themselves or from the 
end-oigans of sensory nerves in general, we are inclined to 
forget that the vaso-motor apparatus mayoperate independ- 
ently of such influences. Emotions, and the state of mind 
in general, greatly influence the caliber of the blood-vessels 
through the vaso-motor system of nerves. Take neuras- 
thenics for a paradigm, and I have examined a large number 
of them at different periods under emotional influences, 
intense mental application, and when their brains were at 
rest, and in each instance my results varied. Emotional 
influences and intellectual application increased blood- 
pressure, while mental rest reduced it. Blood -pressure is 
also influenced by physical activity, ingestion of food, mens- 
truation, etc. In other words, blood -pressure, to me, signifies 
nothing unless one takes into consideration the vaso-motor 
factor. 

Concerning the vaso-motor factor, the following con- 
clusions may be formulated : (i ) Blood -pressure is an expres- 
sion of action of two chief factors — ventricular force and 
vasoconstriction, (a) The inhalation of amyl nitrite dissipates 
the vasoconstrictor factor and brings into play the ventric- 
ular force, whidi is the real factor to be encouraged in a 
&Qing heart. (3) The vasoccmstrictor factor may and does 
compensate TOitricular inadequacy, for it is essential in most 
cardioarterial diseases for the blood -pressure to be main- 




B I d ^ - Pressure 

variation. In the erect posture blood -pressure rises, owing 
to compensatory arteriole contraction, and this difference 
between recumbency and standing varies, according to my 
measurements with the Riva-Rocci instrument, between 15 
and 30 mm. In vaso-motor insuflSciency the postural 
variations are reversed, and this is especially true in neuras- 
thenia, notably, the angiopathic form, and in the form 
described by the author as "splanchnic neurasthenia," where 
the blood shows an abnormal tendency to accumulate in the 
splanchnic area. I regard a continuously maintained high 
Wood-pressure as the most constant factor in the etiology of 
arteriosclerosis, and, further, consider that the poisons 
absorbed from the intestinal canal are largely responsible 
for such high tension. The latter factor is easy of deter- 
mination. 

Vaso-motor biethod of testing cardiac sufficiency. — 
As remarked before, blood -pressure is the resultant of two 
chief factors, viz.^ force of the cardiac ventricle and vaso- 
constriction. Remove the latter, and the ventricular force 
will come into play. Blood -pressure as taken ordinarily 
means nothing, for it is difficult to gauge how much of it is 
due to the action of the vaso-motor nerves and how much to 
the condition of the heart-muscle. The heart may be very 
weak, and yet show high blood -pressure, because vasocon- 
striction compensates a failing heart. The method is, briefly, 
to take blood -pressure in the usual way ; next have the patient 
inhale amyl nitrite from a bottle until the physiologic action 
(flushing) of the drug is secured, at which time again take 
the blood -pressure. In the norm the average increase of 
the pressure after the inhalation is from 6 to 10 mm. In 
cardiac enfeeblement there is a fall instead of a rise of 
pressure, and the degree of fall is proportional to the degree 
of myocardial insufficiency. All my investigations were 

241 



made with the Riva-Rocci instrument. Clinicians have un- 
reservedly accepted the dictum of the physiologist that the 
nitrites lower the blood -pressure. The latter may be true 
with toxic doses, but my clinical investigations show that 
amyl nitrite inhalations will, in the norm, cause the pressure 
primarily to fall, but the systolic pressure immediately rises. 
It has been shown experimentally that if a nitrite is intro- 
duced into the cerebral circulation and prevented from 
attaining the general circulation, there is no fall in the blood- 
pressure. 

Arteriosclerotics, according to my clinical observa- 
tions, may be classified as follows: (i) Those with high 
blood -pressure and strong cardiac tones who show.after amyl 
nitrite inhalations, a stabile or a slight rise of blood -pressure. 
Here the cardiac musculature is not yet compromised. 

(2) Those with high blood -pressure and enfeebled cardiac 
tones, who show after the inhalation a decided decrease of 
blood -pressure. In this, as well as the succeeding class, the 
reduction in blood-tension is influenced by the elimination 
of the tonus of the arteries, which was maintained by the 
vaso-motor system of nerves, thus allowing the true endo- 
cardial pressure, which is enfeebled, to be brought into action. 

(3) Those with relatively low blood -pressure and enfeebled 
heart tones who demonstrate a still further reduction of 
pressure after the inhalation. In a prognostic sense the 
latter class of arteriosclerotics belong to the hopeless category, 
insomuch as the vaso-motor system of nerves is either 
exhausted or unable to properly usurp the functions 
failing heart. 

Test for administering heart tonics. — All card! 

tonics may bo divided into direct or indirect; the former 

acting by direct stimulation of the heart; the latter, by 

improving the nutrition of the organ or by relieving vi 

242 



B I 



u 



tension and hastening the output of blood from the heart. 
I select a reliable infusion of digitalis for diagnostic purposes. 
In the therapeutic stadium — i, e., after its administration 
for about three days — it has a dual action, slowing the pulse 
and augmenting blood-pressure. The latter is the product 
of two forces— increased heart-work and augmentation of 
the vessel-tone. Now, it is evident that digitalis may do as 
much harm as it does good. Supposing, before giving 
digitalis, we noted that the blood -pressure was 218 mm., and 
that after the inhalation of amvl nitrite it was reduced to 
190 nmi. ; that after the use of digitalis it was 215 nmi.. but 
the amyl nitrite inhalation reduced it to 150 nun. Now, the 
theory of action of the drug on the patient was practically as 
follows : The blood -pressure was essentially the same after 
as before the use of digitalis, but while amyl nitrite before the 
use of digitalis reduced the blood-pressure only 28 mm., 
after its use the pressure was reduced 65 nmi. This would 
indicate that the digitalis was unfavorable in its action, for, 
after the tonus of the blood-vessels was removed by amyl 
nitrite, the greater reduction in blood -pressure demonstrated 
that the cardiac force was further reduced after than before 
the use of digitalis. In other words, digitalis was goading a 
jaded heart, and the high blood -pressure was illusory. 

This action is not uncommon in the administration of 
digitalis, owing to its vasoconstrictor influence, and when the 
latter implicates the coronary blood-vessels, the nutrition of 
the heart must suffer. In the case just mentioned digitalis 
showed an unfavorable action, but when it was given in 
combination with diuretin, which antagonizes the vaso- 
constrictor components of digitalis, the action of the latter 
drug was more favorable, the blood -pressure falling only 
15 in lieu of 65 nun. Any of the nitrites may be combined 
with digitalis or strychnin when the vasoconstrictor effects of 

243 



Spondyloth e r a p y 

the latter are undesired. Strychnin^ like many other drugs, 
has been discredited as a heart tonic because clinical meas- 
urements of the blood -pressure show no rise. The fact is 
that the vaso-motor mechanism which supplements the 
cardiac vigor increases the blood tension when the latter 
is enfeebled, and diminishes it when the cardiac strength is 
not involved. After adequate doses of strychnin hypoder- 
matically, the vaso-motor method of estimating pressure 
shows the cardiotonic properties of strychnin. In all 
instances cardiac auscultation and sphygmomanometry are 
necessary for estimating the action of cardiotonics. The 
sphygmomanometer only gauges the force of the left ventricle, 
and to determine the sufficiency of the right ventricle, 
auscultation of the cardiac tones is alone adequate. The 
cardiac chambers, even in health, are not constant as 
far as their diameters are concerned ; on the contrary, they 
contract and dilate; in other words, their capacity tends 
to diminish with increasing cardiac vigor; hence percus- 
sion shows an increase or diminution in the area of cardiac 
dullness according to whether the heart is insufficient or 
sufficient. 

SPHYGMOMANOMETRY. 

The instrument employed for estimating blood -pressure 
is called a sphygmomanometer and it is as essential to the 
physician as is his clinical thermometer. All sphygmomanom- 
eters are based on the principal of circular compression 
of the arm by an arm-piece, B (Fig. 66.), connected with 
a manometer (^4 ) and an inflating apparatus (C). When 
the arm -piece is sufficiently tight to obliterate the pulse at 
the wrist, the height of the mercury in the manometer 
indicates the maximum systolic pressure. With the in- 
struments of Janeway and Stanton, the diastolic pressure 

244 



S p h y g m omanometry 

can also be obtained. The highest pressure in the pulse- 
wave is the systolic; the lowest, the diastolic; and mean 
pressure signifies the average of systolic and diastolic 
pressures. For all practical purposes it is sufficient to esti- 
mate the systolic pressure, for it is more often modified by 
pathol(^c conditions than the diastolic pressure. The 
diastolic pressure in a normal pulse is 25 to 40 mm. below 




the systolic pressure, and in high tension it may be as low 
as 50 to 80 mm. Many circumstances modify our clinical 
results, and certain precautions must be taken with the use 
of all sphygmomanometers. All observations must be made 
with the patient in the same position ; the arm-piece should 
be applied at the heart-level and should fit accurately. A 
wide arm-piece (12 cm.) must be employed. The con- 
nections must consist of non>distensible tubing. It is, of 
245 



. 



course, betkT to employ an instrument which measures 
systolic and diastolic pressures. 

The author has frequently noted in his observations the 
jx)ssibility of mistaking his own pulsations for those of the 
patient. To obviate this error in estimating blood -pressure, 
he places a rubber ring at the base of his index-finger to 
exclude the blood, and consequently the pulse from the 
latter (Fig. 67). 

TREATMENT OF HYPERTENSION. 

The drugs employed for reducing a high blood -pressure 
are known as vasodilators. They produce paral)'sis of the 
vasoconstrictor mechanism, which is first manifested in the 



Fic. 6 7, ^Rubber- ring for tiriuding 




-pulsations. 



4 



face by dilatation of the cutaneous blood-vessels (blushing). 
The redness is not confined to the face, but may extend 
over the entire trunk. With the flushing there is also a sense 
of heat, throbbing of the blood-vessels, headache, quickening 
of the pulse and respiration, and ringing of the ears. The 
veins are likewise dilated. The dilatation of the arterioles 
and veins of the splanchnic area leads to a decline in the 
general arterial pressure. In the administration of the 
drugs of this class one must push them sufliciently to seci 
their physiologic effects, and then reduce the dose or s 
the drug when the patient complains of throbbing ori 
feehng of fullness in the head. Some patients show! 
246 



High Blood -Pressure 

remarkable idiosyncrasy to drugs of this class, reacting to 
insignificant doses, whereas others are resistant to very large 
doses. It is evident, then, that one must begin with small 
doses to test individual susceptibility. 

Among the drugs used for lowering blood -pressure are 
the following: 

1. Amyl nitrite^ which is employed by inhalation. Its 
action is manifested within fifteen seconds and the 
symptoms disappear within three minutes. 

2. Erythrol tetranitrate (tetranitrol). Its ejffects appear 

only after an hour and they last about five hours. 
Dose, one-half to two grains, usually in tablets. 

3 Nitroglycerin (trinitrin). This drug acts in about 
two or three minutes, but its effects only last from 
one- half to three hours. It is official as a one per 
cent alcoholic solution; Spirilus glyceryUs nitratis, 
dose, one to three minims. 

4. Sodium nitrite^ given in doses of from two to three 
grains. It corresponds in rapidity and duration of 
action to trinitrin. 

5. Potassium iodid, although not an active vasodilator, 
clinical observations show that by its prolonged 
use, a lowering of blood-pressure may be achieved, 
probably in consequence of its vasodilator action. 

6. High blood-pressure is often maintained as a result 
of augmented tonus of the vaso-motor center, and 
is quite independent of vascular disease. It is 
essentially a nervous phenomenon. Give such 
subjects sufficiently large doses of hromids for 
several days, and it will be noted that there is a 
considerable fall in the blood-pressure. 

In the opinion of the author, pharmacotherapy is not 
always satisfactory in the treatment of hypertension for the 
reason that toleration for the vasodilators is rapidly acquired 
and for the additional reason that their action is evanescent. 

247 



Spondylo therapy 

From what has preceded, one is justified in concluding 
that, hypertension is often a condition which is desirable 
and not to be opposed, insomuch as the vasoconstriction 
may compensate a failing heart. In such instances, vaso- 
constrictors are injurious and the correct couree to pursue is 
to strengthen the heart and the blood -pressure will fall of 
its own accord. 

The latter effect may be rapidly attained by concussion 
of the spinous process of the *jth cervical vertebra or more 
slowly by the administration of digitalis. 

The following case is cited as a paradigm of many like 
cases illustrating the preceding fact. 

A patient has a blood-pressure of 240 nun. Auscultation 
and percussion of the heart demonstrate cardiac enfeeble- 
ment. Concussion of the spinous process of the 7th cervical 
vertebra is executed (duration of stance, 5 minutes). The 
blood -pressure is again taken and found to have fallen 
30 mm. Each day thereafter, concussion is executed and, 
at the end of about ten days, the blood-pressure has fallen 
to 165 mm., the area of cardiac dullness is diminished and 
there is a decided strengthening of the heart -tones. Later, 
in consequence of over-exertion, an examination of the heart 
shows cardiac enfeeblement and the blood -pressure has 
risen to 200 mm., but with repetition of the concussion- 
treatment, the pressure falls to 165 mm. 

Now, in a case like the preceding, an examination of the 
heart would not have been necessary to justify the conclusion, 
that the high blood -pressure was only an expression of 
cardiac enfeeblement; estimating the blood -pressure before 
and after the concussion-treatment would have sufficed to 
warrant the deduction. 

Many erroneous conclusions are formulated concerning 
the vigor of the heart by aid of auscultation. Here, it is 

248 



Hypertension and Hypotension 



BHHnBaBOBBB^BBIBBBBBBaBa 



assumed, that accentuation of the second aortic tone suggests 
vigor of the left ventricle of the heart, yet one may hear 
very loud heart-tones in anemic and emaciated persons. 
The fact is, that two factors contribute to the genesis of the 
tones of the heart, viz,^ muscle and valves, and it is often 
difficult to distinguish the prolonged and dull sound of the 
former from the short and sharp sound of the latter. 

CONCUSSION IN HYPERTENSION AND HYPOTENSION. 

The writer has established empirically that, one may 
rapidly reduce the blood -pressure by applying the concussor 
(large enough to include two spinous processes, Fig. 50) 
of a vibratory apparatus yielding a forcible percussion 
stroke to the spines of the 2nd and yd dorsal vertebrcB and 
maintaining the seance for about five minutes. Hundreds of 
investigations thus made convince the author that, by this 
method, one is in possession of a means for reducing pressure 
heretofore unattainable by pharmacotherapy, insomuch as 
the results are more rapid and lasting. The following are 
the records of two arteriosclerotics : 

1. Mrs. W. 

Blood-Pressure before vibration of the 2nd and 

3rd dorsal spines 225 mm. 

One minute after vibration 218 mm. 

Two minutes after vibration 185 mm. 

Three minutes after vibration 178 mm. 

Fifteen minutes after vibration 180 mm. 

Thirty-five minutes after vibration 178 mm. 

Two hours after vibration 172 mm. 

The following day 168 mm. 

2. Mr. S. 

Blood-Pressure before vibration 228 mm. 

Two minutes after vibration 232 mm. 

Five minutes after vibration 210 mm. 

Eighteen minutes after vibration 200 mm. 

249 



S p ondylo therapy 

Not infrequently, the primary result of concussion is 
manifested by a temporary rise of pressure followed by a 
decided fall which attains its maximum in about two hours 
time. One must not assume, however, that the results in 
hypertension are always uniform. In some instances no 
effect is achieved, and the author is constrained to believe 
that, in such cases, the hypertension is due to cardiac 
enfeeblement, and it is only after toning the heart that a 
fall of blood -pressure occurs. 

When the blood -pressure is diminished in arteriosclerotics 
by aid of concussion, it is usual to find a heart showing 
little or no enfeeblement. If there is no fall of pressure 
following concussion of the 2nd and 3rd dorsal spines and 
and a fall is only observed after concussion of the yth cervical 
spine, the high pressure is caused by cardiac weakness and 
concussion of the spine in question is indicated to reduce 
pressure which it does by toning the heart. 

If a patient has certain symptoms which one assumes 
are caused by the arterial hypertension, a reduction of the 
latter by the foregoing method (concussion of the 2nd and 
3rd dorsal spines or 7th cervical spine) suggests the correct- 
ness of the diagnosis and the treatment conducted along the 
same lines will prove in a relative sense, curable. 

Thus in cerebral arteriosclerosis, the patient may have 
headache, vertigo, transient pareses or aphasia. If, following 
concussion, there is diminished arterial-tension and an 
abatement of symptoms, the diagnosis is suggested. 

LOW BLOOD -PRESSURE. 

(Hypotension. ) 

A systolic pressure below 100 nmi., suggests hypotension 
and is observed in wasting diseases, infections, hemorrhages, 
collapse and shock and after the use of vasodilators. 

250 



Low Blood "Pressure 

Suprarenal insufficiency. — The ^^tache cerebrale'^ is 
a red line with white borders produced by drawing the nail 
over the skin. It is a vaso-motor phenomenon present in 
typhoid fever and meningitis, and is without diagnostic 
significance. Sergent directed attention to a "white line," 
which is the converse of the tache cerebrale. Like the latter, 
it is evoked by drawing the finger-nail across the abdominal 
skin. Within thirty to sixty seconds a white line appears, 
which persists from two to five minutes. Sergent found the 
line in Addison's disease and in a number of specific fevers, 
all of which were characterized by low arterial-tension. In 
these cases he found that the administration of suprarenal 
extract caused the white line and the low tension to dis- 
appear. He therefore regards this line as useful in the 
diagnosis of suprarenal insufficiency and in affections of 
the capsules. Other French writers have confirmed this 
observation. The white line is caused by a reflex spasm of 
the capillaries, and can be provoked in vasodilatation and 
in conditions of low vascular tension. There is much reason 
to question the constancy of the white line as a diagnostic 
s)rmptom. Thus, de Massary failed to observe the sign in 
six cases of Addison's disease, even though the arterial 
tension was very low. Griinbaum finds that the oral ad- 
ministration of suprarenal extract to normal individuals 
does not cause a rise of blood -pressure, and that when a rise 
follows exhibition of the drug by the mouth, it indicates 
suprarenal inadequacy. In doubtful cases the blood -pressure 
is accurately determined, and then 3-grain doses of the 
extract are administered thrice daily for three days. The 
pressure is again estimated, and a distinct increase is very 
suggestive of Addison's disease, provided there is no valvular 
lesion of the heart. Suprarenal insufficiency should be 
tested whenever asthenia and pigmentation are present. 

251 



S p ondylo therapy 



■B^^aaSBBBBBESBBSBB^^OB^BBBBB 



The latter are the chief symptoms of Addison's disease, but 
are likewise present in many other diseases. If there is no 
bronzing in Addison's disease the application of a mustard 
plaster will draw the pigment to the surface of the skin. 

Neurasthenia is often associated with hypotension, in 
fact, it is the only demonstrable sign in these cases. Such 
patients usually complain of obscure abdominal symptoms 
(splanchnic neurasthenia) and this is not surprising 
considering the fact that the loss of vaso-motor tone conduces 
to a large accumulation of blood in the abdominal veins. 

TREATMENT OF HYPOTENSION. 

It is exceedingly injudicious practice as a routine method, 
to have recourse to symptomatic treatment, but insomuch as 
physicians are human and not divine, such treatment is 
often imperative and indeed efficacious, when the causal 
factor is not demonstrable. 

Thus, in hypotension, many drugs are efficient for 
influencing collapse and the drugs used for this purpose are 
the following: Strychnin, camphor, caffein, strychnin and 
ether. 

The foregoing cardio-vascular stimulants, however, are 
only temporary in their action. 

Much was expected of adrenalin in the treatment of 
hypotension, but, unfortunately, disappointment has attended 
its employment. 

This agent causes a decided rise of blood -pressure, due 
to its vasoconstrictor action on the blood-vessels and by its 
direct action on the heart. It causes retardation and 
strengthening of the heart-beat. The vascular constriction 
is most pronounced in the splanchnic and muscular vessels, 
and feeble or absent in the cerebral and pulmonary vessels. 

252 



-vj 



B I 



r e s s u r e 



The renal vessels are first constricted, with diminished flow 
of urine, but dilate with larger doses and increased flow of 
urine. The augmented blood -pressure almost immediately 
succeeds the use of the drug, but it is of short duration. It 
has been found that vasoconstriction is of greater duration 
than the rise of blood -pressure, and this is explained by the 
fact that the stimulating effect on the heart is of less duration 
than the stimulating action of the arterial musculature. 

The bath -treatment of tjphoid-fever has demonstrated 
that, the water has a decided hypertei^ive action on the 
vaso-motor system and that it produc^« rise of the blood- 
pressure. 

The latter result demonstrates th| 
that cold water acting as a periphei 
provokes the heart reflex and, in.sol( 
ventricular systole is the primaj 
the latter rises. 

Now, the author has repeatS 
are many individuals showing caj 
there is no response on the part c 
to compensate the failing heart, 
enfeebled heart by means of digital 
spine of the 7th cervical vertebra results i 
pressure. 

The author has established empirically that concussion 
of the spines of the 6th and jtk dorsal vertebra will raise the 
blood-pressure. The results, however, are not as uniform 
as is the method for reducing blood -pressure, and not 
infrequendy, the effects are only noted after a lapse of about 
two hours. 

If the latter method is effective, the results are relatively 
permanent and many neurasthenics with hypotension can 
bear testimony to the foregoing statement. 
253 




pertinent fact 
neous stimulant 
the force of the 
.blood -pressure, 

ted that there 
ment in whom 
itor mechanism 
;thening of the 
icussion of the 
a rise of blood- 



S p 



t h 



r a p y 



The duration of the seances is about the same as when 
concussion is employed in hypertension. 

ANEURYSM OF THE THORACIC AORTA. 
THE AORTIC REFLEXES. 

The course of the upper surface of the normal aorta in 
the adult of middle life may be projected on the thorax by 




drawing a curved line, beginning at a point corresponding 
to the right sternal line in the middle of the first intercostal 
space and ending at the point of insertion of the first left rib 
to the sternum (Fig. 68). The highest point of the aortic 
arch is distant about 5 cm., and the beginning 2 cm., from 
the anterior thoracic wall, hence a forcible percussion blow 
(which is propagated to a depth of 5 cm.) cannot fail to 
elicit the dullness of the aortic arch if dilated. 



A 



R 



f I 



In the norm, the transverse dullness of the aorta at the 
level of the manubrium extends 2 or j cm. to the right of the 
median line of the sternum and 1.5 to 3.5 cm. to the left of 
the medial line. If the transverse dullness at this point 
exceeds 5 cm., the aorta is either dilated or the site of an 
aneurysm. The aorta is nearest the anterior chest-wall at 




the junction of the 2nd right interspace with the sternum. 
From this point as it arches over to the left, it sinks deeper 
into the cavity of the thorax so that it eludes percussion. 

Concussion of the Jour last dorsal vertebras (gth to the 
12th dorsal vertebra) in succession, by a series of sharp, 
vigorous blows will, in the norm, dilate the thoracic aorta 
which can be demonstrated by the x-rays and by percussion. 
Percussion must be executed at once after concussion of the 
vertebral spines in question, insomuch as the duration of 



Spondylotherapy 

the reflex of aortic dilatation is limited (from one-half to 
one minute). Vibrosuppression (page 80) will aid in 
defining the course of the aorta. 

Concussion of the spine of the jth cervical vertebra causes 
a contraction of the thoracic aorta (aortic reflex of con- 
traction). Thus it is, that when one provokes the dilatation 
reflex, the counter reflex of contraction will, at once, dissipate 
the former reflex. 

Percussion of the vertebral spines is executed by means 
of the hammer and pleximeter or the hands (Fig. 3). 

THE AORTIC REFLEXES IN DIAGNOSIS. 

As before remarked, one is able to define by percussion 
the normal area of the arch of the aorta after concussion of 
the four lower dorsal vertebrae. Thus it is, that if the 
diminished resonance or dullness exceeds the norm, either 
the vessel is dilated or it is the site of an aneurysm. One 
may remark that if an aortitis is present, the reflex of dilata- 
tion will reproduce the symptoms peculiar to this affection, 
viz., pains in the upper sternal region extending through 
the mediastinum and to the shoulder and arm. 

A dull area in the upper thoracic region or in the back 
(corresponding to the site of the aorta), if caused by a 
thoracic aneurysm, will show a diminished area of dullness 
when the spine of the 7th cervical vertebra is concussed 
(aortic reflex of contraction), and an increased area of dull- 
ness, when the spines of the four lower dorsal vertebrae are 
successively concussed (aortic reflex of dilatation). Up to 
the present time of writing, the author has examined 45 
cases of aneurysm of the thoracic aorta and has noted an 
absence of the reflex in only two patients in whom the 
aneurysms had attained enormous dimensions. All these 
cases were controlled by skiascopic examinations. With 

256 



Aortic Reflex of Contraction 

the latter> one may note a contraction and dilatation of the 
aneurysmal sac when the spines of the special vertebrae are 
concussed. One may generally observe an almost immediate 
evanescence of pressure-symptoms (dyspnea, cough and 
pains) when the sac is brought to contraction after a single 
s&mce of vibration-treatment applied to the spine of the 
7th cervical vertebra. 

THE AORTIC REFLEX OF CONTRACTION IN TREATMENT. 

It occurred to the writer when he first employed the 
aortic reflexes in diagnosis, that if concussion of the 7th 
cervical vertebra would cause contraction of an aneurysmal 
sac, this fact would prove advantageous in the treatment of 
a thoracic aneurysm. The results achieved have exceeded 
the author's expectations. Only fourteen patients with 
thoracic aneurysm have thus far been treated by the author 
according to his method, but they were all advanced cases. 
Absolutely no results were achieved in one case (the aneurysm 
had attained an immense size and the sac ruptured). This 
much may be said for this treatment that the results usually 
follow after several stances of the concussion-treatment. 
The first case of aneurysm of the thoracic aorta thus treated 
was seen in consultation with Dr. A. J. Sanderson, of 
Berkeley. The following record is presented : 

Treatment was commenced July 7, 1905, on which date 
the patient complained of violent pains in the chest and 
dyspnea on the slightest exertion. On August 2, 1905, the 
x-ray shadow of the aneurysm was denser, and the aortic 
reflexes could not be elicited. The latter I attribute to clot- 
formation in the aneurysmal sac, which inhibited whatever 
elasticity remained in the aortic walls. At this date aneurys- 
mal pulsations could no longer be detected by the rays. 
Dullness, formerly present over the sac on the anterior 
chest-wall could no longer be elicited. Tracheal tugging 

257 



S p n d y I t h e r a p y 

was barely perceptible. The thoracic pains had disappeared, 
and there was no longer any dyspnea on exertion. On the 
first of September, Dr. Sanderson stated that the only 
symptom which remained at the time the patient left his 
home was slight tracheal tugging. In all my cases the latter 
symptom persisted despite the disappearance of subjective 
symptoms. 

Dr. Hubert N. Rowell, of Oakland, directed a patient 
(male, age 56 years) to me, who noted about four years 
before coming, the following symptoms : Cough, pressure in 
the chest, dyspnea and a sensation of suffocation when he 
assumed the recumbent posture. An examination demon- 
strated a large aneurj^m of the arch of the aorta. 

Just before treatment was commenced, the patient could 
not get more than three hours sleep at night owing to 
paroxysmal attacks of coughing and choking. After the 
first treatment he could sleep the entire night, and after two 
weeks' treatment consisting of daily stances (five minutes 
duration) by means of vibration applied to the spine of the 
7th cervical vertebra, the patient was practically well and 
there was nothing to indicate the persistence of his original 
trouble beyond a slight tracheal tugging. During this brief 
period he gained ten pounds in weight.* 

Dr. William Clark, of Alameda, made the following 
notes concerning a patient whom he sent to me for treatment 
on February 26, 1909 : 

Miss G. Age 30 years; native of California. 

Complains of croup at night whenever she catches cold. 

History: Measles, whooping-cough and diphtheria; 
typhoid fever thirteen years ago. Is not sure about 
scarlet fever. Menstrual history normal. About 



♦This patient, re-examined after a year, is absolutely well and shows an increase 
in weight of twenty pounds. 

258 



Aortic Reflex of Contraction 

eight years ago noticed a choking sensation. This 
becoming worse, was the reason for consultation. 
She cannot lie on left side at night; also is quite 
short of breath upon exertion. 

Examination: Fairly developed; eyes protruding; no 
trouble since using glasses; no headaches; has no 
pain. Notices that voice is more husky since I last 
saw her. Is slightly dyspneic at this time. Veins 
on the anterior part of the chest quite dilated. No 
pulsation over upper part of chest noticed. Exam- 
ination of lungs negative. Spleen not palpable. 
An area of slight dullness over upper part of sternum 
and to the right. Loud bruit over the arch of the 
aorta, heard loudest at junction of the clavicle with 
the sternum on the left side; bruit transmitted to 
the subclavian and carotids, more so to the left; 
is also transmitted along the course of the aorta, 
and is' heard over the abdominal aorta; also heard 
posteriorly over the entire course of the aorta. 
Radial arteries apparently not atheromatous. With 
laryngoscope, right vocal cord apparently not as 
active as the left. This, however, may be erroneous, 
as there is considerable difficulty in obtaining a 
clear view, owing to position and contour of epig- 
lottis. No tracheal tugging detected. Left radial- 
pulse possibly more forcible than right. With x- 
ray, pronounced pulsation of the arch of the aorta 
noticed, and arch also noticeably elongated in a 
vertical line. Heart apparently not much enlarged. 

Diagnosis: Aneurysm or dilatation of the aortic arch. 

This patient was examined by the author in association 
with Dr. Clark and the percussional resuUs elicited by 
inducing the aortic reflexes of contraction and dilatation are 
noted in Fig. 71. 

It was noted that, when the aortic reflex of dilatation was 
provoked, there was a temporary aggravation of the dyspnea 

259 



Spondylo t h e r a p y 

and spasmodic cou^, but they vere at once subdued when 
the aorta leBex of omtiaction was elicited. VMthin several 
days after treatment was commented, all the subjective 
sjrmptoms disappeared and after five weeks' treatment by 
percussion-massage of the spine of the 7th cervical %-ertebra 
the patient was practically discharged. The patient's 




Fic. 71. — Aortic reflexes of cootnctioa umI dOaUtioa lepreKnied by the 
dolled lines within aixl without the contiDuoiu line (which lepiesented the area 
fA ancuiyimal dutloess before elkitation of the aoctk reflexes). 

exophthalmos disappeared after a few treatments and further 
reference to this subject is made on page 280. 

It is unnecessary to detail the histories of the other cases 
of thoracic aneurj-sm beyond sa)-ing that the results achieved 
corresponded in the main to the cases cited.* 



Aortic Reflex of Contraction 

Now, a few words are necessary respecting the method 
of treatment. In the therapeutic elicitation of the vertebral 
reflexes, notably, the aortic reflexes, the vibratory apparatus 
which the physician must employ is one giving the percussion 
' stroke. All other motions, such as oscillations, shaking, and 
friction interfere with results; in other words, one must 
select an apparatus which percusses. First, dust some talcum 
powder over the site of the spine of the 7th cervical vertebra 
to avoid irritation from any friction of the pad connected 
with the apparatus; next, cover the spine of the vertebra 
with several layers of lint which are attached to the skin by 
adhesive plaster. After this, the percussion stroke may be 
communicated directly to the spine of the 7th cervical 
vertebra, or indirectly, if the skin is sensitive by interposing 
a strip of linoleum. The daily stances according to results, 
may last from five to fifteen minutes, but during the stance 
the treatment must be interrupted from time to time to 
avoid irritation of the skin. The latter may be avoided if 
the operator directs the patient to inform nim the moment 
a burning sensation is experienced. 

The author only employs the pneumatic hammer (Fig. 
50) for concussion and, insomuch as there is no friction, 
the preceding precautions are unnecessary to avoid irritation 
of the skin. 

In the absence of a suitable apparatus one may employ 
a pleximeter (a strip of linoleum) applied to the 7th cervical 
spine which is struck a series of rapid and moderate blows 
by means of a hammer to the end of which is fixed a large 
piece of hard rubber. It is wise in this method, to protect 
the spinous process with a thick layer of lint. 

The author has not the hardihood to regard his method 
of treatment of aneurysm of the thoracic aorta as curative, 
for time alone is the decisive factor; yet a consen^ative 

261 



d 



a p 



estimate of the results thus far achieved prompts him to say 
that as a palliative method, it surpasses any which has yet 
been recommended to the profession. 

The diagnosis of aneurj'sm of the thoracic aorta, desra 
our physical methods of examination, is often fraught \ 
difficulty, but the latter is minimized if the physician l 
remember the following facts; SjTnptoms suggestive of« 
aneurysm of the thoracic or abdominal aorta are accenti 
after concussion of the spi nes of the four lower dorsal vertei| 
and they are mitigated after concussion of the spine of l! 
7th cervical vertebra, although several seances may 
necessary to note the latter result. 

Further, an area of percussional dullness which enl 
when the four lower dorsal vertebrae are concussed 1 
diminishes when the spine of the 7th cervical vertebi 
concussed, suggests an ancun,-sm. 

It is reasonable to assume that an aneurysm of I 
abdominal aorta would be similarly influenced by 
manceuvers suggested, but the author is in the ] 
of no evidence to permit him to cite a supposition as a faS 



ANEURYSM OF THE ABDOMINAL AORTA. 

Since the foregoing was written, a patient was refen 
to me by Dr. E. N. Torello. The patient in question (n: 
age 65) had excruciating pains referred to the abdomen anT 
thorax for nearly a year, which resisted all methods of 
treatment and necessitated the constant use of analgesics. 
An examination revealed signs of arteriosclerosis and J 
dullness in the left lumbar region; iht area of dullness 1 
creased when the /our lower dorsal sfnnes were concussed a 
diminished when the yth cervical spine was concussed 1 
72). 

Beyond the latter, nothing was demonstrated, althoi^ 
262 



A h d 



1 A 




Fig. 7».— Area of dullness in aneurysm of ihe abdominal aorla. The con- 
IJDuous tine rEpiescnu ihe area oi dullness befote concussion, whcicas ihe dotted 
line within the Litter, is the aortic leflex of contraction (concussion of the 7thcervii:at 
spine), and the dotted line without, the aortic reflex of dilatation (concussion 
of the spines of the four lower dorsal vertebra:). It is interesting to obser^'e that 
the pert:us3ian-sign in question was the only evidence suggesting an aneurysm 
and the diagnoaia was established later by other signs. 



the latter sign suggested an aneun-sm of the, abdominal 
aorta. Some weeks later the author again examined the 
patient with Dr. H, Sawyer, and a definite tumor could be 
felt with an expansile pulsation and a slight thrill. The 
diagnosis having been definitely established, treatment 
consisting of concussion of the spine of the 7th cervical 
vertebra was commenced ; the daily stances lasting about 
ten minutes. After the fourth treatment the pains continued 
with the same intensity {night and day) as before, but the 
pains were strictly localized on the left side of the abdomen, 
Until about the tenth seance, the patient asserted that the 
pains were not mitigated. The latter statement was dis- 
couraging considering the fact that in the author's experience, 
the symptoms of thoracic aneurysm had usually yielded to 
a few treatments. After the tenth stance, however, the 
pains gradually became less intense and analgesics were no 
longer required. 

There was later, however, a decided interruption in the 
improvement of the patient owing to the fact that one 
morning, after considerable straining at stool, the pains 
recurred with almost the same violence as before, but a 
continuation of the treatment by concussion caused the 
pains to disappear gradually, and at the time of writing, 
the patient is practically well. It may also be noted, that 
coincident with the recurrence of pain after straining at 
stool, the dullness in the left lumbar region was demonstrable. 
Straining at stool increases intra-abdominal pressure and 
rupture of an aneurysm is very likely to occur. 

The author wishes to emphasize that in all his aneurysmal 
patients, concussion was the only method of treatment em- 
ployed. Considering the results attained in aneurysms of 
the aorta, it is not beyond the domain of reason to hope for 
like results in aneurysms of other vessels. 
264 



Reflex of Abdominal Aorta 



' REFLEX OF THE ABDOMINAL AORTA. 

The i2th dorsal spine corresponds to the aortic orifice 
in the diaphragm and also to the celiac axis. It is known 
that the most frequent site of an aneurysm of the abdominal 




FlO. 73. — Area of dullness corresponding lo the nth dorsal venebra. and 
lepresenting the reflex of the abdominal aorta after concussion the four lower 
doi^ spines with the hammer and pleximeter (Fig- 2). The increased area of 
the dullness represented by the dotted lines on both sides suggests a dilauiion of 
the aorta, whereas the irr^ulat dotted line on one side suggests an aneurysm. 

aorta is just below the diaphragm in the neighborhood of 
the celiac axis. In the norm, the area over the 1 2th dorsal 
vertebra and to either side yields a resonance on percussion. 
If one strikes in succession the four lower dorsal spines, 
the nonnal resonance over the 12th dorsal vertebra and to 
either side yields a dullness which in the average subject 
measures about 5 cm. (Fig. 73). 

If the lumbar vertebra? show resonance on percussion 
265 



S p n d y loth e r a p y 

prior to the elicitation of the aortic reflex of dilatation, a 
dullness is likewise noted over the four first vertebrae in 
question. 

The dullness over and to the right and left of the 12th 
dorsal vertebra is caused by distension of the aorta. It 
persists for several minutes or may be dissipated at once by 
evoking the counter aortic reflex of contraction (concussion 
of the 7th cervical spine). Vibrosuppression {q. v.) will 
accentuate the dullness. If the dullness at the 12th dorsal 
vertebra exceeds 6 cm. in diameter, one may conclude the 
existence of a dilated aorta and, if the dullness is irregular, 
an aneurysm of this vessel may be suspected. 

Since the author has elaborated the reflex of the abdom- 
inal aorta, he has recognized several cases of abdominal 
arteriosclerosis (by the augmented area of dullness) and by 
concussion of the 7th cervical spine, he has successfully 
treated the cases in question.* 

In this connection the author wishes to refer to the 
valuable observation of Buch. According to the latter, 
arterio-sclerotic abdominal colic is specially amenable to 
theobromin (1.5 to 2 gm. a day), diuretin (3 to 4 gm. a 
day) or tinct. strophanthi (5 to 8 drops three times a day). 
No other form of abdominal colic is thus relieved. 

PHYSIOLOGY OF THE AORTIC REFLEXES. 

Claude Bernard's interesting observations advanced the 
clinical study of vaso-motor phenomena. He found that 
when the sympathetics in the neck of a rabbit were cut, 

♦Thus in one patient, the disease presented the picture of a mucous colUis. The 
abdominal aorta (elicted by the reflex) measured 8} cm. at the 12th dorsal 
vertebra. The attacks had resisted treatment for a year, yet three stances of 
concussion of the 7th cervical vertebral spine, sufficed to ameliorate the 
attacks and they were later inhibited by further treatment. Concussion in 
augmenting the contractility of the dilated aorta merely contributed to the 
value of this vessel as a peripheral pump, thus yielding a better supply o€ 
blood. 

266 



Clinical Observations 

aBaaacBaaaaa aaaaasaeaaaaaaa: s^^^ 

the blood-vessels in the ear on the corresponding side became 
dilated and that if the peripheral ends were stimulated, the 
ear became blanched. Those who are adepts in manual 
therapy find that manual pressure along the vertebral 
column will evoke either vasoconstriction or vasodilation; 
the former by brief and the latter by continuous pressure. 
It is evident that in explaining the genesis of the aortic 
reflex of contraction, one is concerned with stimulation of 
the vasoconstrictor nerves, the centers of which are chiefly 
in the medulla, where they pass into the cord and emerge 
with the anterior roots as preganglionic sympathetic fibers. 
These fibers are not only capable of altering the caliber of 
the vessel, but by means of continuous stimuli passing over 
them, they maintain the tone of the vessels. 

The aortic reflex of dilatation is associated with stimula- 
tion of the vasodilator nerves, the reflex centers of which are 
located in the medulla and throughout the spinal cord. 
From the latter situation, they emerge with the posterior 
spinal nerves. The author seeks to explain the aortic 
reflexes by either stimulation of definite vasoconstrictor 
and vasodilator nerves or their centers in the cord, and he 
has established empirically that concussion of the 7th cervical 
vertebra stimulates the aortic constrictor nerves, whereas 
the dilator nerves are excited by concussion of the spines of 
the foxir lower dorsal vertebrae. 

THE PSYCHOLOGY OF CLINICAL OBSERVATIONS. 

When the author published his original communication" 
on the subject of the aortic reflexes, he was the recipient of 
many letters, the burden of which represented the inability 
of the correspondents to confirm the observations of the 
author. It was impossible to answer all the communications 
at that time and, as this is an opportune moment, I will 

267 



now endeavor to answer some of them. One of the most 
eminent physiologists in this countrj' protested that con- 
sidering the pathologic condition of the walls of the aorta 
in aneurysm of that vessel, it could not in consequence be 
excited reflexly to alternate contraction and dilatation. 
Again, such clinical observations could not be accepted unless 
corroborated by physiologic investigations. No one can 
gainsay the fact that pulsation is an important sign of an 
aneurysm, and insomuch as this phenomenon is dependent 
on the elastic recoil of the walls, it follows, that elasticity of 
the vessel is not annihilated in aneurysm of the vessel. It 
is true, as the author has frequently observed, that the 
walls of the aneurysm do not contract nor dilate equally 
in eliciting the aortic reflexes; in fact, there may be no 
perceptible change under the influence of the reflexes at one 
point, but a decided change at another point, although in 
every instance some perceptible change was obsen'ed. 
Theoretically, at least, the aortic reflex will persist as long 
as the aneurysm pulsates. 

It is now many years since Langenbcck employed ergot 
hypodermatically in the treatment of aortic aneur}*sms. 
He argued, that this drug by stimulating muscular tissue 
produced vasoconstriction and in this action the cure of an 
aneurysm could be effected, A storm of protest was en- 
gendered by this suggestion, his opponents declaring that 
the middle coat of the aorta did not contain suflicient 
muscular tissue to enable it to contract. 

Theoretically, one would suppose that because the aorta 
is almost entirely composed of fibrous tissue, it is not likely 
to possess any contractile power, but it has such a power, 
nevertheless. In the case of a criminal executed at Wiirz- 
burg, it was found to contract by aid of electricity imme- 
diately after death. ^" 

268 



Clinical b s e r v a t i o n s 



Even though the physiologist denies that the aorta pos- 
sesses contractility he must be equally consistent and deny 
the evidence of the x-rays, which prove that the pathologic 
as well as the ph)rsiologic aorta shows contractility. Until 
the advent of the x-rays we accepted the statement of the 
physiologist that the diaphragm flattened with each in- 
spiration, but the rzys demonstrated that its curve is always 
maintained unaltered, and in its excursions it plunges 
piston-wise up and down. Physiologists have always taught 
that the central tendon of the diaphragm is capable of only 
limited movement in respiration, hence the respiratory 
mobility of the heart is likewise restricted. The rays, how- 
ever, disproved the fallacy of this contention as well as 
many others which space will not permit us to cite. 

The clinician no longer regards the pronunciamento of 
the physiologist as apodictic. We have learned to discredit 
many statements emanating from the laboratory-investigator, 
not so much because the observations of the latter are faulty, 
but because there is a considerable difference between a 
laboratory and the bedside and a guinea-pig and patient. 
Many of the facts derived from the laboratory suggest the 
conunent of the mathematician who, having demonstrated 
a new mathematical theory, thanked God that it could not 
be of the slightest utility to any living soul. Neither the 
pathologist nor the physiologist should forget that, "Path- 
ology is the physiology of the sick.'' The presence of broncho- 
dilator as well as bronchoconstrictor fibers in the vagus 
was conclusively established by the physiologic investigations 
of Dixon and Brodie in 1903, yet the author demonstrated 
seven years before by a simple clinical observation that the 
vagus must contain bronchodilator as well as broncho- 
constrictor fibers.*^ 

The final court of decree of the clinician is neither the 

269 



physiologic nor pathologic laboratorj'. To test a given 
function one must compare it with a like function in indi- 
viduals of the same species. Thus, if the same quantity of 
uric acid were excreted in a mammal as is excreted in a 
normal bird, it would have to be regarded as pathologic. 
If disease were wholly a question of demonstrable lesions 
then the pathologist would be compelled to deny the existence 
of the so-called functional diseases. In consequence of this 
conflict between the laboratory and clinical investigator, a 
hiatus has arisen which is now occupied by clinical pathology, 
a branch which endeavors to conciliate scientific and em- 
pirical medicine. Several years ago, the writer observed 
that one could make the record of the pulsations of the head 
and, furthermore, that the cephalograms thus obtained in 
certain subjects were pathognomonic of cerebral arterio- 
sclerosis. Investigating this subject further in the physio- 
logical laboratory of the University Hospital, London, and 
in Paris, the writer did not obtain the slightest clue to the 
cephalic pulsations and he questions, whether he is justified 
in rejecting a clinical obser\'ation which does not permit 
of physiologic demonstration in animals. One vituperator 
condemned my method of treating aneurysms as absurd, 
because it was not responsive to reason. My vituperator 
recalled the erudite German professor of economics who 
received a bed as a present. Until the small hours of the 
morning he busied himself with abstruse calculations to 
determine whether he was large enough for the bed or if the 
latter were large enough for him. Finally, he was struck 
with the happy idea of getting into the bed, and to his intense 
delight discovered that it was admirably suited to his pre 
portions. If my detractor were endowed with the true scia 
tific spirit, he would not have condemned a new method ^ 
treatment without a trial, considering the kaleidoscofl 
270 



Clinical Observations 

changes constantly arising in all branches of science The 
scientist rejoices one day at the birth of a new theory and of- 
ficiates at its burial on the morrow. In 1903, in several issues 
of "7"Ae London Lancet ^^ a discursive polemic was agitated 
on the subject of my "lung reflex." It was quite evident 
that one of the disputants did not rigorously execute the 
method for eliciting the reflex in question but failed to cite 
this reason for condemning it, although others employed 
the reflex as a clinical sign of value. Many new methods 
for a like reason have been relegated, to oblivion. Some 
time ago, while in Paris, the writer found several clinicians 
who elicited the heart reflex as a routine • method of exam- 
ination and appeared quite content with the sign. The* 
writer demonstrated that the sign as elicited was of no 
value, insomuch as when the precordial region was stimu- 
lated, it likewise evoked the lung reflex which also dimin- 
ished the area of cardiac dullness, and that, in consequence, 
one could only rely on the deep area of cardiac dullness 
as an index of myocardial retraction. A prominent Eastern 
clinician spent several days at the author's ofiice inves- 
tigating visceral reflexes. One of the patients submitted 
had an aneurysm of the thoracic aorta. Here the aortic 
reflexes were the object of study. It was impossible to 
convince the clinician that there was any modification of 
the area of dullness after the elicitation of the reflexes, 
imtil the writer compelled him to close his eyes while per- 
cussing, when the results of percussion tallied. 

The author regrets the necessity of obtruding his per- 
sonality in the discussion of this subject, but considering 
the theoretic objections to his method of treatment, he feels 
that any merit attached to it may be obscured by its 
simplicity. 



271 



S p n d y I t h e r a p y 

THE VASO-MOTOR APPARATUS.f 

The muscular walls of the blood-vessels (arteries, 
veins* and capillaries) are under the control of the vaso- 
constrictor and vasodilator nerves. The latter act chiefly 
on the walls of the small arteries (arterioles). If the vaso- 
constrictor nerves are stimulated, the arterioles contract 
and, in consequence, the resistance to the flow of blood is 
augmented, the pressure in the arteries rises and the cap- 
illary and venous pressures fall. A contrary effect is 
produced on stimulation of the vasodilator nerves. The 
nervous mechanism presiding over vascular tone concerns 
jtself with the following : 

1. Ganglia of the blood-vessels; example: pallor from 

cold and hyperemia from heat. 

2. Anomalies of the sympathetic ganglia; example: 

facial hyperemia in lesions of the cervical ganglia. 

3. Reflex action through the spinal cord; example: 

pallor from pain. 

4. Reflex action through the medulla oblongata; ex- 

ample: glycosuria subsequent to sciatica. 

5. Impulses from the cortex of the brain; example: 

blushing. 

The Splanchnic area^ is most abundantly supplied with 
vaso-motor nerves and it is this region which is specially 
concerned in the distribution of blood and the general 
blood -pressure. 

*Mall has shown that stimulation of the splanchnics will cause contraction of 
the portal system and thus send twenty-seven per cent of the total quantity 
of blood in an animal into the right heart. 

fThis subject is further discussed on page 278. 

-tThe splanchnic area includes the vessels supplied to the intestinal tract, liver, 
kidneys and spleen. 

272 



Vaso-Motor Apparatu 



In the norm, by aid of the regulatory mechanism of the 
vaso-motor nerves, each part of the body receives an amount 
of blood necessary for its activity and the greater the latter, 
the more blood it will receive in consequence of vasodilation. 
Simultaneously, the vessels in other parts of the body are 
contracted, and it is by this vascular reciprocity between 




Fig. 74. — Illustrating the path of a vasoconstrictor nerve; A, anterior root, 
showing the course of the preganglionic fiber as a dotted line; D.V., dorsal and 
ventral branches of the spinal nerve; R, ramus communicans; G, sympathetic 
ganglion. The postganglionic fibers in each ramus come from the sympathetic 
ganglion with which it is connected. The preganglionic fibers entering at any 
ganglion may pass up or down to end in the cells of some other ganglion ^owell). 



the different regions, that the normal blood -pressure is 
maintained. 

Vasoconstrictor or dilator effects may be produced at 
the periphery by means of vaso-motor reflexes. Thus, if the 
right hand is immersed in cold water, the temperature falls 
in the left hand, and one also observes the red cheek on 
the implicated side in pneumonia. The vaso-motor reflex 
consists of sensory impulses which enter the spinal cord 
with the posterior nerve-roots and by irritating the centers 
in the cord excite constrictor or dilator effects. The cells 
of the vesicular columns of Clarke are supposed to be the 
seat of the reflexes in question. 



273 



Spondylo therapy 

THE VASOCONSTRICTOR NERVES. 

The vasoconstrictor nerves which supply the skin, 
trunk and extremities, emerge from the ganglion (Fig. 74) 
to the corresponding spinal nerve by way of the gray ramus, 
and, after attaining the spinal nerve, they accompany it to 
its corresponding region. 

The chief center for the vasoconstrictor nerves is in the 
medulla, but throughout the entire length of the spinal 
cord (excepting the cervical region and lowest part of the 
lumbar region), there are subsidiary centers. 

The majority of the vasoconstrictor nerves emerge from 
the central nervous system in the anterior nerve-roots. 

The following table shows the location of the vasocon- 
strictor neural cells in the segments of the cord : 

DISTRIBUTION. ORIGIN. 

Brain, face, scalp, mucosa of the 2iid, 3rd and 4tb dorsal segments, 
nose, mouth, salivary glands, 
ear and eye. 

Esophagus and stomach. 4th to the 9th dorsal segments. 

Small intestines. 6th dorsal to the 2nd lumbar. 

Liver. 6th dorsal to the ist lumbar 

(chiefly in the loth, nth and 
1 2th dorsal). 

Pancreas, spleen and suprarenals. 8th to the 12th dorsal. 

Large intestines. nth dorsal to the 2nd lumbar. 

Bladder, uterus, external organs nth dorsal to the 2nd lumbar 
of generation, ovaries, testicles segments, 
and prostate gland. 

THE VASODILATOR NERVES. 

These nerves are characterized as follows: 

I. The latent period for their stimulation is longer than 
that of the constrictors. 

274 



aso-Motor Neuroses 

2. It takes a longer time to attain the maximum effects 
on the dilators than it does on the constrictors. 

3. The after-effect is longer. 

4. The vasodilators, unlike the vasoconstrictors, are not 
in tonic activity and they appear in activity only 
during the functional activity of an organ as in the 
case of the erectile tissue of the penis. 

The vasodilator neural cells supplying the blood-vessels 
of the head, scalp, face, eye and mouth are chiefly located 
in the nuclei of the cranial nerves. The vasodilator cells 
for the abdominal organs are found in the nucleus of the 
loth cranial nerve and for the pelvic organs and the testicles 
in the 3rd, 4th and 5th sacral segments of the cord. Vaso- 
constrictor and vasodilator cells for the nutrient blood- 
vessels of the lungs and bronchial tubes (bronchial arteries), 
have been located with a degree of certainty in the 3rd to 
the 7th dorsal segments of the cord. 

PATHOLOGY OF THE VASO-MOTOR NERVES. 
(VASO-MOTOR NEUROSES.) 

A vasomotor neurosis is expressed either as a spasm of 
the vessels (angiospasm) or less often as a paralysis (angio- 
paralysis). 

Angiospasm is characterized by pallor, coldness and 
trophic disturbances. If the spasm affects the superficial 
vessels, the following symptoms occur : sensory disturbances 
(tingling, anesthesia and analgesia) and cutis anserina 
(goose-skin). When the spasm involves larger vessels, one 
observes the condition known as intermittent claudication, in 
which the patient in walking suddenly loses the power in 

his legs* 

Cases of temporary aphasia, nimibness and paralyses 
are provoked by a like anipospasm of the cerebral vessels. 



The veins may likewise be implicated in a spasm and 
the blood, not being able to escape from the capillaries, the 
parts become blue and edematous, nutrition is impaired 
and gangrene may ensue. 

AuGioPARALYsrs may be caused either by diminished 
function of the vasoconstrictor nerves or by excessive action 
of the vasodilators. The symptoms are similar to those 
observed in spasm of the veins {vide supra). In the con- 
dition known as causalgia, the blue, cold and edematous 
part is associated with severe pains of a burning character. 

In the condition known as erytkromelalgia, pain, tender- 
ness and congestion of the soles of the feet are associated 
with a burning pain not unlike that produced by a blister, 
The vaso-motor phenomena occur paroxysmally and are 
resistant to treatment. 

Another vaso-motor neurosis is the so-called angioneurotic 
edema, in which there is a sudden swelling of some part 
(face, neck, larynx or an extremity). 

Loss of vascular tone is observed in neurasthenia, hysteria 
and at the menopause ; there are sudden flushes or pallor. 

Individuals with a "poor circulation" have cold hands 
or feet or the face is constantly congested. 

We have also the less understood visceral angioneiiroses 
characterized by hj-peremia, transudations and ecchymoses. 

There is an old Latin aphorism, "Naiuram morborum 
curaliones ostendunt" (cure shows the nature of diseases). 
In this sense, the pathology of many diseases is revealed by 
the results of treatment. In accordance with the preceding 
aphorism, the author contends that, there are many diseases 
regarded as distinct affections which are merely symptomatic 
of a fundamental condition, inz., instability of the nervous 
mechanism which controls local vascular tone. This faul 
mechanism, which the author is pleased to call angio-c 



A n g i p a r a lysis 

has already been referred to on page 275. It is reasonable 
to assume that the chief dereliction of action of this mech- 
anism is resident in the vaso-motor centers of the spinal cord. 
The author submits the following classification of 
angioneuroses based on the results of treatment : 

ANGIOSPASM. 

Symptoms: no vaso-motor reflex on irritation, skin 
shrunken or thrown into folds, arrested metabolism and 
function due to insufficient blood-supply and sensory dis- 
turbances (numbness, tingling, anesthesia and analgesia). 

Angiospastic affections, i, intermittent claudication ; 
2, temporary paroxysms of paralysis, aphasia or hemianopsia 
due to spasm of the cerebral vessels ; 3, reflex spasm of the 
vessels of the leg in sciatica. Nothnagel has reported five 
cases of the latter affection which eventuated in partial 
paralysis, sensory disturbances and atrophy; 4, Raynaud*'s 
disease; 5, migraine; 6, akroparesthesia. 

ANGIOPARALYSIS. 

Symptoms : red or mottled appearance of the skin, sub- 
jective sensation of heat, sensory disturbances (hyperesthesia 
and hyperalgesia), notably, a burning sensation (causalgia). 
The primary symptoms of redness and heat are usually 
succeeded by blueness, cold and impaired nutrition. The 
taches c^6brales of Trousseau, formerly regarded as path- 
ognomonic of meningitis, is essentially an angioparalysis in- 
dicating enfeebled vasoconstrictor action. The sign is 
elicited by slight irritation of the skin with the finger-tip or 
a pencil ; a white line appears followed by a bright red dis- 
coloration which persists for several minutes. Dermato- 
graphism is closely related to the foregoing sign : wheals in 
Keu of a white spot or line appear after cutaneous irritation. 

277 




Angioparalytic affections : i , erythromelalgia ; 2, 
acrodynia; 3, aneurysm; 4, exophthalmic goitre; 5, diabetes; 
6, coryza; 7, cold extremities; 8, angioparalytic symptoms 
of the neuroses ; 9, certain toxic conditions. 

Some of the foregoing conditions will be described more 
fully under treatment of the vaso-motor neuroses. 

TREATMENT OF THE VASO-MOTOR NEUROSES. 

The author presents the following table of the vaso-motor 
nerves in relation to the spinous processes, the object being 
to stimulate clinical observations in the treatment of the 
vaso-motor neuroses which is conceded to be a difficult 
matter : 

ORIGIN OF THE VASOCONSTRICTOR NERVES. 

AREA SUPPLIED. DERIVATION. RELATION TO SPINOUS 

PROCESSES. 

Head. First three dorsal nerves. 6th and 7th cervical spines. 

Arm. Seven upper dorsal nerves. 6th cervical spine to the 

4th dorsal spine. 

Leg. Five lower dorsal and first 5th to the 9th dorsal spine. 

lumbar nerves. 

Abdominal Viscera. Splanchnic nerves which are 2nd to the 8th dorsal spine. 

made up of fibers from 
the 5th to the 12th dorsal 
nerves inclusive. 

ORIGIN OF THE VASODILATOR NERVES. 

AREA SUPPLIED. DERIVATION. RELATION TO SPINOUS 

PROCESSES. 

Buccofacial region. 2nd to 5th dorsal nerves. 6th cervical to the 2nd 

dorsal spine. 

Eye, head and ear. 8th cervical and ist dorsal 6th cervical spine. 

nerves. 

Arm. Five upper dorsal and last 5th cervical to and dorsal 

cervical nerves. spine. 

Leg. 6th to the 12th dorsal 3rd to the 8th dorsal spine. 

nerves, inclusive. 

In the experience of the author the foregoing table is of 
slight value in treatment with relation to the vasoconstrictors 
of the head, arm and abdominal viscera (page 349), but it 

278 



Vaso- Motor Neuroses 

serves of no value in influencing the vasodilators in treat- 
ment. 

In eliciting the aortic reflexes (page 254), vasoconstriction 
of the aorta is best attained by concussion of the yth 
cervical spine and vasodilation, by concussion of the spines of 
the four lower dorsal vertebrce. 

The author has found that the same rule holds good for 
practically all the vessels of the body, and this fact simplifies 
the treatment of thevaso-motor neuroses. Of all the methods 
investigated by the author for influencing the vaso-motor 
centers in the spinal cord, no method is comparable to that 
of concussion; in fact, it is the only method. Even in the 
norm, if concession is executed over the 7th cervical spine, 
usually within a minute, vasoconstriction as evidenced by 
some pallor is noted in the hands, face and feet, whereas 
concussion of the four lower dorsal spines overcomes the 
constriction and redness and even congestion substitutes the 
pallor. These effects are more conspicuous when there is 
a diminished function of either the constrictors or dilators. 
Naturally, the conspicuity of pallor or redness is merely 
relative, and one must look sharply for the change. 

The author has treated a very large number of patients 
with vaso-motor instability (angio-ataxia) and, when the 
affection was characterized by angiospasm, the four lower 
dorsal spines were concussed, whereas in angioparalyses, 
concussion of the 7th cervical spine was executed. 

Results were achieved in practically all instances after 
repeated treatment, provided a reaction could be elicited, 
i.e.j when concussion of the 7th cervical spine would replace 
hyperemia by anemia, and when concussion of the spines 
of the four lower dorsal vertebrae would substitute hyperemia 
for anemia. 

Very often the reaction could not be noted until after 
several treatments. 



S p n d 



I 



a p y 



Migraine (hemicrania ; sick headache). — The palholdgj- 
of this disease is obscure and the innumerable affections lo 
which its origin has been attributed probably act as exciting 
factors of a basic condition, viz., angio-ataxia. Many 
writers regard migraine as a vaso-motor neurosis; in fact, a 
former classification of two varieties of the affection is no 
longer viewed with tolerance by clinicians: i, an angio- 
spastic form characterized by pallor of one side of the face; 
2, an angioparalytic form, manifested by redness of one side 
of the face. Those who support the vaso-motor theorj- of 
migraine contend that the early symptoms are caused by 
vasoconstrictor and the later symptoms by vasodilator 
influences. The author has treated about eight cases of 
migraine by concussion of the 7th cervical spine based on 
the theory of instabihty of the vaso-motor centerin the spinal 
cord. The attacks were subdued in four cases, relieved in 
two patients and the attacks in two other patients were un- 
int^uenccd. The treatment must be executed in the inter- 
parosysmal periods. 

Exophthalmic goitre (Grave's, Basedow's or Parry's 
disease). — This disease is characterized by protrusion of the 
eyes (exophthalmos), enlargement of the thyroid gland, 
tremor and rapid heart-action (tachycardia). The theory 
which has gained most favor in explaining the symptoms of 
the disease is, that it is caused by a hypersecretion (hyper- 
thyroidism) of the thyroid gland conducing to a kind of 
chronic intoxication. There is, however, a gap in the theory 
which evades the question. What causes the hyperthyroidism ? 
Based on the results of his treatment, the author is con- 
strained to believe that the disease is essentially an angio- 
paralytic affection and that stimulation of the vaso-motor 
center in the cord by concussion of the 7th cervical spinous 
process suffices to relieve and even cure the affection i 
280 



aso-Motor Neuroses 

question. Every successful method of treatment in this 
disease, medical or surgical, has been directed toward a 
reduction in the size of the thyroid gland, and it is reasonable 
to assume that one can stimulate or diminish the activity of 
this gland by increasing or diminishing its circulation. 

Among the symptoms which yield most rapidly to treat- 
ment by concussion are tachycardia, flushing and tremor. 
Among six cases of the disease treated by the author the 
latter signs, plus the enlarged thyroid, were improved after 
a few treatments by concussion, but the exophthalmos in all 
but two cases persisted (although less pronounced). In all 
the cases, a decided retraction of the protruded eyes was 
noted after each treatment. 

The following notes concerning one patient suffice to 
illustrate in the main the results of treatment : 

The patient presented all the cardinal symptoms of 
the disease. The pulse-rate was i6o; tremor involved 
practically every muscle of the body; the slightest exer- 
tion was associated with perspiration; the thyroid was 
enlarged. 

After the third treatment by concussion, the pulse 
was 130, and after the eighth treatment, it was reduced 
to 88, and so remained after the patient was discharged. 
After the fifth treatment, the tremor was perceptibly 
diminished and perspiration following exertion no longer 
occurred. As shown in illustrations (Figs.7 5, 76), although 
the exophthalmos persisted, it was less conspicuous, 
whereas the thyroid gland is practically normal in size. 

Diabetes mellitus. — The pathology of this disease is 
obscure. In the celebrated piquire experiment of Claude 
Bernard, diabetes in an animal can be produced by irritating 
the floor of the 4th ventricle. Since then it has been shown 
that irritation of other parts of the nervous system will 

281 



S p n d y I the rap 

produce diabetes. In consequence of the preceding, there 
has arisen a neurotic theory of diabetes which supposes it 




Fig. 75.— Photograph of a patient with czophthatmlc gcuue. 

to be caused by a vaso-motor paralysis, resulting in a g 
quantity of blood flowing through the liver. 

The author, giving credence to the latter theory, 

282 



so-Motor Neuroses 

ated ten diabetics by concussion nf the spine of the 7th 
vical vertebra* and the result- ll'iws: 




1. No results in three cases. 

3. The percentage of sugar very much reduced in four 



le aulhor wishes to emphasize the following: In lesling the methods ol Ireal- 
ment employed [hroughoul this book, recourse was had lo no other therapeutic 
procedure. Not even ttsl, bo essential in the treatment of aneurysm, was 
enjoined. 



k 



3. Slight reduction in the percentage of sugar in one 
case. 

4. Disappearance of glycosuria in two oises. The 
duration of treatment in the latter cases extended 
over a period of one and two months respectively. 

CORVZA (Cold in the Head). — The prevention and 
treatment of this condition is a constant rebuke to progressive 
medicine, insomuch as we have added nothing to that con- 
tributed by our medical ancestors. The sequels of a cold 
in the head include affections ranging from sinusitis to 
cerebral abscess. The prevailing theory regards corj'za as a 
nasal infection varying in virulency according to the microbal 
cause. If, however, it were wholly an infection, then in a 
region so accessible to the employment of bactericides, llie 
latter must be discredited. The infectious factor must be 
regarded in the same light as any other peripheral irritant 
which, acting reflexly upon the vaso-motor center, causes all 
the symptoms of an angioparalysis. This angioparalysis 
need not necessarily be excited from the nasal mucosa but 
from other vulnerable areas. The vaso-motor theory of 
coryza is partially sustained by the author's method of 
treatment, i>iz., concussion of the yth cen'tcal spine. When 
the latter is executed in the incipiency of the affection, it 
may be aborted. Later, it modifies the condition either by 
diminishing its severity or by altering the character of the 
discharge. 

When the nose is obstructed in consequence of congestion 
of the nasal mucosa, a few concussion -blows on the spine 
of the 7th cervical vertebra will often overcome the obstruction 
as effectually as cocain, and the relief thus obtained may 
last from minutes to hours. 

Very often the author instructs a friend of the patient to 
strike the spinous process (after the manner shown in Fig 
284 



so-Motor Neuroses 



3), whenever the nose is obstructed or, to execute it as a 
method of treatment, several times a day. 

Naturally, the spinous process will become sensitive 
when concussed repeatedly and, in this event, it may be 
struck at difiFerent angles — directly or on one side or the 
other. 

In asthmaj reflexly provoked by congestion of the nasal 
mucosa, concussion as cited by giving immediate relief to 
the nasal congestion will inhibit the asthmatic paroxysm. 
The nasal mucous membrane is continuous with the lining 
membrane of the pharynx. Eustachian tubes, larynx, trachea 
and bronchial tubes and concussion is equally influential for 
weal in acute congestion of the same membrane irrespective 
of location. Thus many acute congestions of the bronchial 
mucosa may be aborted by concussion of the 7th cervical 
spinous process. 

Cold extremities. — ^This frequent condition has never, 
to my knowledge, been dignified by a technical name, and 
the author proposes the term acropsychrosthesia, signifying 
a feeling of cold in the extremities. 

The effects of cold upon the skin (dermatitis congelationis) 
as in that common condition known as chilblain or pernio 
are really caused by insufficiency of the vaso-motor apparatus 
and the writer has successfully treated this obstinate con- 
dition by repeated * stances of concussion of the spinous 
process of the 7th cervical spine. During treatment, if the 
parts are hyperemic, one may note definite areas of anemia 
in the hands, feet or face. 

Many circulatory disturbances in the face, notably acne 
rosacea^ are likewise vaso-motor neuroses and they also yield 
to the foregoing method of treatment. 

Angioparalytic neuroses. — In neurasthenia, hysteria 
and other neuroses, the vaso-motor symptoms seem to 

285 



dominate the clinical picture. Here the patient complains 
of pulsations throughout the body, notably the head, and 
the face is observed to be in a condition of hyperemia. Keu- 
rasthenics have a symptom in common : a feeling of bea\7 
weight or constriction about the head. Charcot graphically 
described the head -sensation as the "casgtte neuraslheniqw" 
a feeling as though the patient were wearing a tight-fitting 
helmet. The author has never encountered in the literature 
any explanation of this phenomenon, and he is constrained 
to conclude that it is a vaso-molor symptom considering the 
beneficial results of treatment consecutive to the employ- 
ment of concussion of the spinous process of the 7th cer\'ical 
vertebra. 

Toxic conditions. — During the change of life or 
MENOPAUSE, the vaso-motor disturbances are almost as 
common as the arrest or irregularity of the menses. Flushing, 
heat and perspiration alternate with pallor and chills, and 
these symptoms often persist despite treatment to the end 
of life. 

Digestion -AUTOINTOXICATION. — The author employ 
this term to signify a train of vaso-motor symptoms peculiar 
to some individuals who, after the ingestion of a meat, suffer 
from fullness and pulsations of the head, followed by throb- 
bing in the arteries throughout the body. In association 
with these signs, the patients are depressed or despondent 
and are disinclined to execute their routine work. These 
symptoms are regarded as neurasthenic, but they are really 
due to autointoxication. Our conception of the latter 
affection is faulty, insomuch as we regard its causation to be 
associated with putrefaction of albuminoid food in the 
intestines. We forget that there are also poisonous album- 
OSes. i.e., intermediate products manufactured in the 
digestion of albuminous foodstuffs, and investigations show 
286 



Vaso-Motor Neuroses 

that an aqueous extract of the contents of the small intestine 
is infinitely more toxic than an extract made from the 
contents of the large intestine. 

Patients suffering from digestion-autointoxication ex- 
perience relief as a rule, several hours after a rep^t. 

In the treatment of these patients, the exclusion of 
albuminoid food is beneficial, but the best results are achieved 
if the vaso-motor center, which bears the brunt of the dis- 
turbance, is made resistant to the action of the poisons. 

Here, treatment by concussion of the 7th cervical spine 
has given me excellent results. 



287 



S p n d y I the r a p y 



CHAPTER VIII. 

THE RESPIRATORY APPARATUS. 

PHYSIOLOGY — HISTOLOGY — ^POSTURAL LUNG-DULLNESS — ^LUNG REFLEX 
OF DILATATION — LUNG REFLEX OF CONTRACTION — ^PULMOMAIY 
ATELECTASIS — ^BRONCHIAL ASTHMA — SPASMODIC BRONCHOSTEN- 
OSIS — ^TUBERCULOSIS — HEMOPTYSIS. 

PHYSIOLOGY. 

npHE object of respiration is to exchange gases between 
^ the tissues and the external air. The blood circulating 
through the lungs absorbs oxygen from the alveolar air and 
yields its gaseous products of decomposition, notably carbon 
dioxid. 

There are two phases of respiration: 

1. Inspiration, which is efiFected by elevation of the 
ribs and by contraction of the diaphragm. 

2. Expiration, which is a passive act and requires no 
muscular effort. 

In man, the diaphragm predominates over the rib-lifting 
muscles, and the reverse is the case in women; hence, the 
normal type of respiration in man is abdominal, and in 
women, costal. 

When this type of respiration is reversed (page 85), it 
becomes the fundamental condition of many respiratory 
neuroses and accentuates the symptoms of organic aflfections 
of the lungs. 

In Fig. 77, two extreme types of respiration are indicated : 
A, the diaphragmatic, and B, the thoracic type. In A, 
there is no thoracic movement, but the anterior abdominal 
wall during inspiration projects to i. In B, on the contrary, 

288 



Respiratory Mechanis 



the thoracic wall moves forward and upward, whereas the 
abdominal wall instead of projecting is really drawn in. 

The RESPIRATOHY MECHANISM (Fig. 78) Is regulated by 
the respiratory center in the medulla oblongata, the so- 
<alled noeoA vital of physiologists, which corresponds in 
position with the vagus-nuclei. The muscles which enlarge 
and diminish the size of the thoracic cavity are innervated 




Fio. 77. — Diaphngmatk breathing in a m«le And the thotack type of bieatbbg 

by nerves derived from the spinal cord; the diaphragm is 
supplied by the 3rd and 4th cervical roots and the phrenic 
nerve. 

The motor nerves for the muscles of the larynx and 
bronchi run in the trunk of the vagus. 

HISTOLOGY. 

It is now known that longitudinal as well as circular 
muscular fibers exist in the finer bronchial tubes of rabbits, 
and Aufrecht has shown that a powerful layer of circular 
and a weaker layer of longitudinal fibers exist in man- 



S p 



I 



t h 



r a p y 



These bronchial muscles are under tlie influence of the vagi 
and can be made to contract and relax as the result of 
stimulation of the vagi. Thus we have bronchoconstriclor 
and bronchodilator fibers in the vagus. 

The chief bronchoconstrictor reflexes are elicited from 
the mucous membrane of the nose and larynx. 




Fio. 78. — Diagram of ihe respiratory 



The bronchial musculature is further discussed on page 
308. 

Recently, the presence of vaso-motor nerves in the lungs 
has been absolutely denied. 

The author has referred"' to a condition known as 

POSTURAL LUNG-DULLNESS. 

Any one, however, reasonably skilled in percussion will, 
when attention is called to the fact, recognize a decided 
difference in the percussion note of the lungs if percussion 

290 



Postural Lung - Dullness 

is made first in the erect and then again in the recumbent 
posture. One will also note a difference if the patient is 
percussed first leaning far forward and then backward (sup- 
ported by an assistant). In other words (the author is 
assimiing an average typical normal subject), the percussion 
changes correspond in a minor degree to the alterations in 
the percussion note when fluid is present in a pleural space. 
The changes noted would be as follows : 

Leaning far forward: Anterior chest region diffused 
dullness, especially marked in a definite area. Posterior 
chest region hyperresonant. 

Leaning far backward: Posterior chest region shows 
diffused dullness, notably in a definite area. Anterior chest 
wall elicits a hyperresonant percussion note. 

Leaning to one side: Side of chest wall toward which 
patient inclines shows dullness, whereas the other side is 
hyperresonant. 

Lying on one side: Side of chest on which the patient 
lies demonstrates dullness of the lung, including the apex, 
whereas the other side is hyperresonant. 

Recumbent posture: The anterior thoracic wall is decid- 
edly more resonant than in any other posture. 

Prone posture: The posterior thoracic region is more 
resonant than in any other posture. 

Exaggerated Trendelenburg: Slight dullness of the 
pulmonary apices ; lower chest region hyperresonant. 

Differential Diagnosis: Postural dullness as a patho- 
logical phenomenon is frequently encountered and may be 
confounded with the dullness of atelectasis. Dullness 
dependent on atelectasis is usually circumscribed and may 
be dispelled by a series of forced inspirations, rubbing the 
skin over the area of dullness to provoke the lung reflex of 
dilatation and by the cocain test (page 297). 

291 



Postural dullness is usually diffused, involving one or 
more lobes, and cannot be dispelled by forced inspirations, 
the cocain test, or by exciting the lung reflex. The dullness 
in question, however, disappears at once by a complete 
change in the posture of the patient. Assuming, for example, 
that the dullness is somewhere over the posterior surface of 
the chest, its dissipation cannot be effected until the patient 
assumes the prone posture. 

Etiology of Postural Dullness. — After a careful consid- 
eration of this subject the author is constrained to conclude 
for the following reasons that the dullness provoked by 
posture is dependent on the blood normally present in the 
blood-vessels of the lungs, which is influenced by gravity, 
like any other fluid : 

I. The blood in the lungs, unlike in other viscera, is 
not restricted in amount, owing to the absence of vaso-motor 
nerves. 2. The area of most pronounced dullness {as 
influenced by posture) corresponds to the situation of the 
largest pulmonary vessels, and is least manifested in areas 
where the vessels are less abundant. 3. In passive conges- 
tion of the lungs observed in cardiopaths, the dullness 
elicited by postural changes is most pronounced. 4. The 
postural dullness is uninfluenced by all the manceuvers which 
act upon either the bronchoconstrictor or bronchodilator 
nerves of the vagus. 

Postural Lung Dullness in Disease. — As already observed, 
postural lung dullness is observed as a normal condition, 
or perhaps, to speak more definitely, in the norm, lung 
resonance is modified by posture. In passive congestion of 
the lungs it is most pronounced. In pulmonary tuberculosis 
I have noted only slight impairment of lung resonance as 
determined by posture, and this observation applies with 
equal cogency to the pretuberculous lung. For this reason 



Postural Lung - Dullness 

I seek to augment the quantity of blood in the apices of the 
hings by having my tuberculous patients raise the foot of 
the bed so that the blood will gravitate toward the apices. 
After this manner I endeavor to induce a passive hyperemia 
of the regions in question. I cannot speak of results, inas- 
much as this innovation has not been subjected to the test 
of time. Sir James Barr, in his erudite Bradshawe lecture 
before the Royal College of Physicians, London, refers to 
the frequency of atelectasis in exhausting diseases, which 
may be mistaken for a pleural effusion. He furthermore 
says : "Atelectasis is often mistaken for hypostatic congestion 
of the limg, and forcible rubbing of the affected side, acting 
through the lung reflex of Albert Abrams, causes some 
expansion of the lung and clears up the percussion note." 
My observations do not tally with the latter. On the con- 
trary, ever since I recognized the method of diflferentiating 
lung atelectasis and lung hyperemia, I am convinced that 
what is frequently regarded as atelectasis is in reality a 
passive congestion. 

Postural Dullness in Treatment. — The empirical treat- 
ment of pulmonary affections by external applications to 
the thoracic wall is fully justified, since the lung reflex of 
dilatation has been recognized. The postural treatment of 
diseases of the lungs is equally justified by the foregoing 
observations of the author. One fact, however, must be 
emphasized, and that is, the posture assumed by the patient 
must be an extreme one. Thus, to contend against hypo- 
static congestioh the patient must assume the prone posture 
at least for a time several times a day. In hemoptysis, the 
correct posture can be determined when the area involved 
in the bleeding yields a resonant percussion note and in- 
dicates the exsanguination of the area in question. 



293 



THE LUNG REFLEX OF DILATATION. 

This reflex demonstrates the important fact that the 
respiratory area may be influenced indirectly by stimuli 
acting on the vagi. In a contribution by Moscucci," the 
suggestion was made that when ether was sprayed over the 
left half of the abdomen, marked reduction in volume of 
the spleen was observed in twelve cases. In repeating the 
experiments, I likewise noticed a decided reduction in the 
area of splenic dullness in all individuals on whom this 
method was tried, irrespective of the fact whether enlarge- 
ment of the spleen existed or not. Investigations convinced 
me that this diminution in the area of splenic dullness was 
not real, but only apparent. When the ether spray was 
directed over the region of the heart, the percussional area 
of that organ was reduced at once; in fact, the superficial 
area of cardiac dullness could be obliterated by the man- 
ceuver. Similarly, when the spray was directed over the 
hepatic region the superficial area of dullness of that organ 
could be reduced at once. When the spray was directed 
over the border of the lungs posteriorly, the lung borders 
could be made to descend from two to four inches, dependent 
on certain conditions. It was further ascertained that dis- 
location of the lung-borders by forced inspiration never 
approached the dilatation of the lungs produced by the 
cutaneous application of the ether spray. Further experi- 
ments demonstrated in brief the tact that the apphcation 
of any cutaneous irritant, whether the latter be mechanic, 
chemic or electric, would always induce acute dilation of Ihf 
lungs. Even in emphysematous individuals the application 
of a cutaneous irritant still further augmented the existing 
lung-dilation. The question naturally arose, by what means 
could we establish the fact that the application of any 



Lung Reflex of Dilatation 

cutaneous irritant would cause acute dilation of the lungs, 
a condition which, it may be mentioned parenthetically, is 
only of a few minutes duration. Such a hypothesis was 
made tenable by the aid of conventional physical signs and 
the use of the fluoroscope. These aids show that when the 
skin is irritated by means of cold, by friction, or by a strong 
Faradic current, lung dilation will ensue. The degree of 
lung dilation is dependent upon the character of the irritant 
and the severity of its application. The response of the lung 
to dilation is always greatest in that part of the lung con- 
tiguous to the source of cutaneous irritation. Lung dilation 
may be recognized by the following physical signs: i. 
Diminished respiratory excursions of the lung borders. 
2. Extension of the pulmonary percussion note and oblit- 
eration of the cardiac and splenic areas of dullness. 3. 
Hyperresonance of the lungs. 4. Obliteration of the apex 
beat. Auscultation is of no value as a physical sign, inas- 
much as the artificial dilation does not last longer than 
three minutes after the source of cutaneous irritation has 
been removed. Lung dilation spreads from the source of 
cutaneous irritation involving primarily circumscribed parts. 
In lungs showing resonance, the latter could always be in- 
creased by cutaneous irritation over the part percussed. 
The x-rays show how the brightness of the lungs is increased 
by cutaneous irritation. By gradually applying the irritant 
to different parts of the skin of the thorax, one may note 
that eventually the entire lung may be made to yield a more 
intense luminosity. This increased luminosity, however, does 
not last longer than three minutes in the average person, 
after which time the lungs resume their normal appear- 
ance. 

In a number of measurements made during the 
study of the lung reflex after cutaneous irritation, I found 

295 



S p ondy I therapy 



s 



the average dislocation of the lower border of the lung, as 
follows : 

Right sternal line 3J cm. 

Right parasternal line 3J cm. 

Right mammillary line 4 cm. 

Right axillary line 6 cm. 

In another communication, I demonstrated that acute 
dilation of the lungs can be evoked in healthy persons by 
irritation of the nasal mucosa and conversely, that this con- 
dition can be dissipated after the removal of the source of 
irritation. The pulmonary neurosis of dilation can be 
obtained by firmly compressing cotton in both nasal cavities. 
The degree of lung dilation with its concomitant phenomena 
will naturally vary according to circimastances which modify 
other reflex acts. After the introduction of the cotton, a 
few moments elapse before percussional results are noted. 
One will then observe superresonance and inmiobilization 
of the lung-borders and diminution of the areas of hepatic 
and cardiac dullness, in the latter instance, even to obliter- 
ation. Irritation of one nasal cavity with cotton does not 
yield manifest results. If the mucosa of both nasal cavities 
has been thoroughly cocainized before the introduction of 
the cotton, no lung dilation ensues. I have frequently en- 
countered in my clientele, individuals presenting the sympto- 
matic picture of pulmonary vesicular emphysema in whom 
wa'^' associated, some abnormity of the nose. The anomaly 
was a simple coryza, spurs, deflection of the septum, hyper- 
trophic rhinitis or polypi. At any rate, after eradication of 
the nasal anomaly, the symptoms of pulmonary dilation 
disappeared. The form of emphysema here cited is in 
reality an acute lung dilation, an eradicable condition dis- 
sociated with the anatomico-pathologic conditions conven- 
tionally allied with emphysema. The typic clinical picture 

296 



L u n g^ Reflex of Dilatation 

of ax:ute lung dilation could nearly always be made to dis- 
appear by the aid of the cocain testy which constitutes in 
this form of pulmonary neurosis a diagnostic aid of unques- 
tioned value. After application of a solution of cocain to 
the nasal mucosa, the lung-borders will recede and the lung 
resonance and normal vesicular respiration are restored. 
In patients suffering from asthma of presumable nasal 
origin, impaction of cotton in one or both nasal cavities 
may induce a typic asthmatic paroxysm. This fact is of 
undoubted diagnostic value. I maintain that the phenomena 
of lung dilation can be provoked at any point in the extensive 
course of distribution of the pneumogastric nerves, and that 
the stimuli may act indirectly on the vagi through the 
terminal fibers of the trigeminus or, by irritation of the 
cutaneous sensory nerves contiguous to the lungs. 

It is necessary to hypothesize the existence of two 
distinct functions of the vagus nerve, or, at any rate, different 
fibers, with two distinct functions — fibers which can dilate 
(bronchodilator nerves) and fibers which contract (broncho- 
constrictor nerves) the lungs upon application of the appro- 
priate stimuli. In the action of these two sets of nerve 
fibers, the vasoconstrictor and vasodilator nerves of the 
vaso-motor system may be cited as analogous. 

It may be interesting to observe that the author's hypo- 
thesis concerning the existence of bronchodilator and 
bronchoconstrictor fibers in the vagus was confirmed seven 
years later by the well-known physiologic investigations of 
Dixon and Brodie. 

Respecting the diagnostic value of the lung reflex, atten- 
tion has already been directed to its importance in percussion 
(page 204). 

In England, Auld and Sir James Barr, and in Italy, 
Plessi, direct reference to the reflex in the differentiation of 

297 



Spondylo therapy 

atelectasis and consolidation of the lirng; in atelectasis, 
irritation of the skin contiguous to the affected area wiD 
convert the dullness into resonance, whereas if the dullness 
is due to a consolidation, the lung reflex will not influence 
the dullness. 

In x-ray examinations of the lungs, an area of opacity 
due to atelectasis may be mistaken for consolidation; the 
lung reflex would immediately clear the opacity in atelectasis 
but would not influence the shadow caused by a consolidation. 

Cesare Minerbi, of Ferrara, Italy, regards the absence 
of the lung reflex posteriorly as one of the earliest and most 
trustworthy signs of pulmonary tuberculosis. This con- 
clusion was based on a study of 300 cases and 14 autopsies. 

THE LUNG REFLEX OF CONTRACTION. 

Cherchevsky directed attention to a sign of early arteri- 
osclerosis. He found that in the norm, the diameter of the 
aorta varies at different times. It became dilated if the 
region of the chest over the arch of the aorta is struck with 
the percussion hammer, while it shrinks in size if the blows 
are struck in the epigastrium. In arteriosclerosis it is 
impossible to produce these variations in diameter. 

Cherchevsky has misinterpreted the phenomenon ob- 
tained by his manoeuver. What he really elicits is a cir- 
cumscribed lung-contraction adjacent to the part struck on 
the chest by the hammer and the blow on the epigastrium 
merely causes the collapsed lung-area to dilate (lung reflex 
of dilatation), thus supplanting dullness by resonance. 
Dullness may be elicited in practically any chest-region by 
using a plexor and pleximeter. The circumscribed dullness 
thus induced lasts but a few seconds, but may be made to 
disappear at once by striking the epigastrium. 

Observed with the x-rays, the lung reflex of contraction 

298 



Pulmonary Atelectasis 

is an interesting study. After the blow is struck, the adjax:ent 
lung-area becomes gradually dark, showing that the air has 
been expelled from the lungs, whereas in a few seconds the 
lung-area becomes bright again. This lung reflex of con- 
traction cannot be obtained if the nasal mucosa has been 
previously cocainized. 

This reflex may be elicited from the nasal mucosa or the 
vertebral region so that both lungs are brought simultan- 
eously into a condition of contraction and when the reflex 
is thus obtained, it proves of great therapeutic value in the 
treatment of asthma (page 312). 

PULMONARY ATELECTASIS. 

The proponent of any new method of treatment, may, 
in his enthusiasm, permit the imagination to run riot, thus 
presenting assumptions which can neither be demonstrated 
nor corroborated by experience. 

The author has endeavored to avoid the Scylla and Char- 
ybdis of medical theorists and, for this reason, will only 
discuss certain diseases of the respiratory apparatus which 
experience has taught him can be successfully combated by 
methods advocated in this book. 

It is the accumulation of our experiences, observes 
Mundy, that makes our empirical knowledge, at last, scien- 
tific fact. 

Pulmonary atelectasis or lung-collapse, refers to a con- 
dition in which the vesicles of an entire lung or only lung- 
areas are collapsed and contain little or no air. 

We may here disregard the many causes of atelectasis 
and confine ourselves to the discussion of two frequent causes : 
T. Obstruction somewhere in the air-passages (atelectasis 
of obstruction) ; 2. Defective expansion of the chest. 

Acute bronchitis is a common and very rarely a serious 

299 



4 



V 



S p 



I 



t h 



r a p y 



disease in healthy adults. In young and old subjects. Iio"- 
ever, there is always danger of an extension of the catarrhal 
process downwards to the finer tubes, thus conducing to an 
atelectasis of obstruction. Such atelectatic areas are fre- 
quently the site of broncko- pneumonic patches or, as it is 
also called, capillary bronchitis. The author has frequently 
observed that in children suffering from broncho-pneumonia, 
the areas of dullness are not wholly due to the broncho- 
pneumonic condition, but to adjacent areas of atelectasis 
which may be readily be dissipated by elicitation of the 
lung reflex (page 294). 




Defective expansion of the chest. — Any loss of 
inspiratory power may induce lung-collapse independent of 
any other factor. Weak and rickety children with their 
feeble muscular development lack this inspiratory power and 
one observes this enfeebled power in old age, long con- 
tinued fevers and in individuals who are bedridden. 

Even in the norm, certain portions of the lungs are 
collapsed and deprived of sufficient air to yield a dullness 
and. in some instances, flatness on percussion. Not infre- 
quently, th« apex of the lung in its entirety may be atelectatic 
and for this reason alone, some individuals have been pro- 
300 



ulmonary Anemia 

nounced phthisical by physicians who fail to recognize 
atelectasis of the lung. These areas of lung-collapse or 
ateteckUic zones, as the author has called them, usually dis- 
appear after a series of deep inspirations or upon application 
of the lung reflex test (page 298), i.e., by vigorous rubbing 
of the skin over the site of atelectatic dullness. 

Not infrequently, reflex irritation of the bronchocon- 
strictor fibere in the vagus by some anomaly of the nasal 
mucosa may maintain a condition of atelectasis. In the 
latter instance, cocainization of the nasal mucosa by inhibit- 
ing the action of the constrictor fibers will translate the 
dullness of an atelectatic patch into resonance. 

In the accompanying illustrations (Figs. 79 and 80), a 
composite picture is projected defining the usual situation of 
atelectatic zones based on an examination of over one 
hundred apparently healthy individuals (children as well 
as adults). 

These zones are frequently mistaken for areas of lung- 
consolidation, either when detected by percussion or seen at 
an x-ray examination. The zones bear a definite relation 
to the points of election and paths of distribution of the 
lesions in chronic pulmonary tuberculosis and they are 
frequently present in what the author has called "pulmonary 

ANEMIA." 

The latter condition is more frequent in children than 
in adults and fails to yield to ferruginous preparations. The 
syndrome of anemia, however, disappears after a course of 
methodic respiratory exercises. Should the anemia reappear, 
its recrudescence is almost invariably associated with a 
reappearance of the zones of atelectasis.* 



♦For a more extended discussion of the subject of pulmonary anemia^ the reader is 
referred to the author's books, Diseases of the Hearty page 46, and Diseases 
of the LungSt page 20. 

301 



S p n d y loth e r a p y 

TREATMENT OF PULMONARY ATELECTASIS. 

Among the various methods for expanding the lungs 
and thus opposing the condition of atelectasis, the following 
manoeuvers are suggested : 

1. By action on the cutaneous sensory nerves. 

2. By forced voluntary breathing. 

3. By developing the muscles of respiration. 

4. By aid of posture. 

5. By vertebral concussion. 

The two latter methods are advocated in cases of emer- 
gency. 

I. — We have abeady shown that the lung reflex of 
dilatation and the heart reflex of contraction may be evoked 
by cutaneous stimulation. The stimulation of the respiratory 
center is greater through the cutaneous nerves than through 
the branches of the vagus to the respiratory organs. In 
animals which have been made apneic, cutaneous stimulation 
induced strong respiratory movements. We must therefore 
regard cutaneous stimulation as a simple and powerful 
stimulant of the centers of circulation and respiration. 

The empirical treatment of pulmonary affections by 
external applications (poultices, friction with liniments and 
hot and warm compresses) to the thoracic wall is fully 
justified, since the lung reflex of dilatation has been recog- 
nized. 

In acute pulmonary affections, and in infectious diseases 
like typhoid, the author employs carbonated baths and the 
cutaneous irritation thus induced powerfully influences 
cardiac and pulmonic vigor. In these affections we must be 
prepared to dismiss antipyresis as the great desideratum in 
the acute infectious diseases. 

II. — Forced voluntary breathing may be achieved by 

302 



Bronchial A s t h 



m a 



respiratory exercises and for rapid lung-development, the 
aid of the pneumatic cabinet is unquestionably the best 
method. 

in. — Feebly developed muscles of the thorax may be 
strengthened by stimulation of the respiratory muscles 
peripherally or, better still, centrally (to secure symmetrical 
development, page ii), by aid of the sinusoidal current. 

rV. — Reference has been made to postural lung-dullness 
on page 290. Here it is important to recall the necessity of 
frequent and complete changes in posture to obviate the 
tendency to atelectasis and passive congestion of the lungs. 

V. — Concussion of the spines of the third to the eighth 
dorsal vertebrae will provoke a rapid dilatation of both lungs, 
thus inducing the lung reflex of dilatation which, however, 
is of short duration only; hence the necessity of a frequent 
repetition of the manoeuver. 

Other rapid methods of eliciting the latter reflex are : 

1. Stimulation of the nasal mucosa by irritating vapors ; 
strong vapors like those of ammonia must be avoided owing 
to their inhibiting action on the heart (Fig. 56). 

2. By tapping the epigastrium lightly. Here, forcible 
percussion like the ^^Klopf-Y ersucK^ of Goltz, will inhibit 
the heart's action. 

•3. By placing the patient in a warm bath and directing 
cold water from a pitcher to strike the nape of the neck and 
flow down the back. 

BRONCHIAL ASTHMA. 

If we regard this affection as a distinct neurosis of the 
respiratory apparatus, it may be defined as a series of 
paroxysmal dyspneic attacks in which no organic disease 
can be recognized in its causation. Whatever the etiologic 
factor, three conditions are essential : 

303 



S p n d y I t h e r a p j 

1. Diminished resistance of the center of respiration. 

2. Asthmogenic points somewhere. 

3. Irritation of the asthmogenic points. 

The asthmogenic point may exist anywhere in the course 
of the distribution of the vagus nerve, or the bronchocon- 
strictor fibers of this nerve may be irritated reflexly. 

The usual sources of irritation are: 

1. The nose. Here a probe may detect some sensitive 
spot (asthmogenic point) and irritation of this spot may 
induce a typic asthmatic paroxysm or symptoms approaching 
it like dyspnea or a feeling of constriction about the chest 
In these cases of asthma of nasal genesis, if the nose is 
firmly packed with cotton (considering the fact that no 
asthmogenic point can be detected), an asthmatic attack 
may be elicited. A spray of cocain introduced into the nose 
may inhibit a paroxysm of asthma if it is of nasal origin. 
It is better in such cases to cocainize first one, and then the 
other nostril to determine which side of the nose is respon- 
sible for the irritation. By so doing, the side on which the 
nasal anomaly is present may be corrected and thus cure of 
the asthma may be effected. 

2. The asthmogenic point may be located in the larynx 
(pharyngo -laryngeal asthma). Here, likewise, the pfobe 
may be used for diagnostic purposes. 

3. The point of irritation may be intrabronchial de- 
pendent on bronchial catarrh and one observes in the inter- 
paroxysmal period all the symptoms of bronchitis. It is 
difficult, however, to determine during an asthmatic par- 
oxysm which of the rdles heard during auscultation are due 
to bronchitis and which to bronchial spasm. This question 
is determined by the author by having the patient inhale 
nitrite of amyl and carrying it to its full physiologic effects ; 

J04 



Bronchial Asthma 

the fOUs due to spasm will disappear temporarily, whereas 
the fOUs of bronchitis will persist. 

4. The source of irritation may be the stomach (dys- 
peptic asthma) caused by indigestion. Here an emetic or 
vomiting may inhibit an attack.* Intestinal worms may 
also cause asthma (asthma verminosum). 

Among other causes of asthma may be briefly mentioned 
the sexual apparatus in men and women, the kidneys (renal 
asthma), the heart (page 212), malaria, hysteria, neuras- 
thenia, etc. 

Suggestion, as a factor, often casts discredit on the 
etiology of asthma just the same as it does on any other 
neurosis. The operations of the gynecologist and rhinolo- 
gist, and the treatment of the neurologist act in many 
instances by the mere suggestion which is thrown out by 
the therapeutic manoeuvers. 

If asthma can be produced by suggestion, the same 
factor can cure it. Thus odors, particularly of flowers, may 
bring on an asthmatic paroxysm, and one physician induced 
an attack by allowing the patient to smell an artificial rose. 

Of late, exposure of the chest to the action of the x-rays 
in asthma has been followed by cure, and here again, sug- 
gestion cannot be excluded. Thus I recall a patient who 
was brought to my office for an examination of the chest. 
She had asthma and the x-rays were used for a diagnostic 
object, yet her physician whom I saw several months later 
assured me that the patient was cured. She was under the 
impression that the rays were used for a therapeutic object 
and a single exposure sufficed to cure her. 

There are numerous conditions, the number of which is 
rapidly multiplying, which are operative in etiology, and 

^yide page 330, concerning the etiology of asthma from odois. 

305 



Spondylo therapy 

which, when corrected, lead to the cure of asthma. To 
relegate asthma to the category of the neuroses is a simple 
task, but to do so will deprive many sufferers from ultimate 
recovery. The trend of modem medicine is to deny the 
existence of functional diseases as mere entities, but to 
endow them with distinguishing attributes. 

THEORIES OF CAUSE. 

1. Spasm of the bronchial muscles. 

2. Paral)rsis of the bronchial muscles leading to loss of 
expiratory power (Walshe). 

3. A bulbar neurosis consisting of an excessive reflex 
irritability of the center of respiration (See). 

4. A spasm of the diaphragm (Wintrich). 

5. A spasm of the inspiratory muscles (Budd). 

6. A microbic inflammation of the bronchial tree 
(Berkart). 

7. Hyperemia of the bronchial mucosa analogous to 
urticaria (Clark). 

8. The asthma-crystals found in the sputum of asth- 
matics irritate the peripheral ends of the fibers of the vagus 
and induce reflex spasm of the bronchial musculature 
(Leyden). 

9. Swelling of the bronchial mucosa as demonstrated by 
tracheoscopic examination (Stoerk). 

10. An exudative bronchiolitis which induces expiratory 
dyspnea (Curschmann). 

11. Epilepsy of the lungs (Trousseau). 

Among the more recent theorists, Kingscote contends 
that a dilated ventricle (right) of the heart predisposes to 
and maintains a condition of chronic asthma. He assumes 
that a paroxysm occurring at night is associated with the 
recumbent posture; the dilated heart striking the vagi 

306 



Bronchial A s t h 



m a 



which Ke immediately behind the heart on the bony spine. 

The theory of Haig assumes that the uric acid in the 
blood irritates the vagi. 

The x-rays, in the opinion of the author, who has exam- 
ined many asthmatics during a paroxysm, show the in- 
correctness of several theories. Thus, while the diaphragm 
is retarded in its excursions, it is not sufficiently inunobile 
to warrant the theory of diaphragmatic spasm. 

Again, the heart does not approximate the spine in the 
reomibent posture to the extent of obliterating the triangular 
space between the heart and the spine; hence the author 
cannot accept the theory of Kingscote. 

A study of the pathologic anatomy of bronchial asthma 
reveals the pertinent fact that nothing is suggested con- 
cerning the etiology of the disease and even the pathologist 
in consequence, contends that it is a reflex neurosis. 

We are thus constrained to determine the pathology of 
the disease by clinical observations.* 

Based on clinical observations, the author assumes the 
following theory concerning asthma : A spasm of the circular 
muscular fibers of the bronchi with inability on the part of the 
weaker {paralytic) longitudinal fibers to expel the residual 
air imprisoned by the spasm of the circular fibers. 

The foregoing mechanism has its analogue in the bladder 
musculature, when, in consequence of a spasm of the 
sphincter vesicae, the weak detrusor vesicae cannot expel the 
urine and ischuria spastica results. The spastic retention 

• 

♦A. G. Auld (The Lancet, Oct. 17, 1903), in commenting on "THE LUNG RE- 
FLEX OF ABRAMS," observes, "It was not, however, until recent years 
that anything like a satisfactory demonstration of the presence of broncho- 
dilator, as well as bronchoconstrictor fibers in the vagus was made by Roy 
and Brown, and during the present year this seems to nave been conclusively 
established by the work of Dixon and Brodie. But it undoubtedly stands to 
the credit of Abrams to have proved, at least, seven years since, by a simple 
clinical observation that the vagus must contain bronchodilator as well as 
bronchoconstrictor fibers." 

307 



S P n d y I 



t h 



a p y 



of air in the lungs during an asthmatic paroxysm is schemali- 
cally represented in Fig. 8i. 

In supfwrt of the author's spasmo- paralytic kypoikns 
of asthma, the following evidence is presented : 

t. Histologic and physiologic facts. 
3. Clinical (acts; A. The picture of the asthmatic 
parojcysm; B. Results achieved by treatment. 




FiQ. 8i. — A, the normal appearance of the terminal branch of a bronchial 
tube; B, in consequence of a spasm of the circular fibers (he bronchial lube is 
partially occluded and, insomuch as this occlusion cannot be combated by the 
enfeebled longitudinal tibets (which can, In the norm, open the bronchial lubes 
when the latter are contracted) the retention of air causes a dilatation of the lung- 
:s peripheral to the site of occlusioa. 



Aufrecht" has shown that the musculature of the finer 
bronchi consists of a stout layer of circular and a weaker 
layer of longitudinal fibers. The clinical observations of 
the author, which were subsequently confirmed by the 
physiologic investigations of Dixon and Brodie, demonstrate 
that the vagus contains fibers which can either dilate or 
constrict the bronchi. The lung reflex of dilatation (page 
294) demonstrates the predominant action of the circular 
fibers of the bronchial musculature, whereas the countt 
308 



itci^ 



Bronchial Asthma 

reflex of lung-contraction (page 298), shows the predominant 
action of the longitudinal fibers. 

In asthmatics, the lung reflex of contraction is obtained 
with difl&culty owing to enfeeblement of the longitudinal 
fibers, hence any therapeutic manoeuver which will accen- 
tuate this reflex will arrest asthmatic paroxysms and will 
prevent their recurrence. This is the basis of the author's 
method of treatment in bronchial asthma. 

In the norm, the lung reflex of contraction may be elicited 
in the following ways : 

1. By forcible concussion over any area of the lungs by 
means of a plexor and pleximeter. This manoeuver will 
only elicit a circumscribed lung reflex of contraction (page 
298). 

2. By inhalation of antyl nitrite after previous cocainiza- 
tion of the nose. Here the lung reflex of contraction, as 
evidenced by dullness of the lungs on percussion, is most 
conspicuous in the infraclavicular regions. It will be noted 
that amyl nitrite inhalations are currently employed to arrest 
an asthmatic paroxysm, but its effects are usually transitory. 
The reason for this is evident. Any irritant to the nasal 
mucosa will provoke the lung reflex of dilatation, but if the 
nasal mucosa is previously cocainized, amyl nitrite, like 
many other drugs, will reflexly stimulate the broncho- 
constrictor nerves and by inducing the lung reflex of con- 
traction will arrest an asthmatic paroxysm. 

3. There are several preparations used in a nasal 
atomizer which are eflficacious in arresting an asthmatic 
paroxysm but which are not curative. One is a secret 
preparation known as the Nathan Tucker remedy. 

Coincident with the relief attending its use, the hyper- 
resonant lungs become dull on percussion and the dullness 
is always in proportion to the relief obtained. In other 

309 



Spondylo therapy 

words, this preparation by provoking reflexly from the nose 
the lung reflex of contraction brings relief to the asthmatic. 
From various analyses made of the Tucker remedy, some 
claim that no cocain is present, but according to the obser- 
vations of the author, it is impossible to obtain any decided 
effects without its presence. The author suggests the fol- 
lov/ing as a cheaper substitute for the Tucker remedy: 

Cocain 3 per cent. 

Atropin sulphate gr. ii. 

Natrii nitrosi gr. ix. 

Glycerin gr. xxx. 

Aquae desdl oz. ss. 

M.S. — ^Atomize for two minutes in each nostril and 
inspire deeply. 

It may be necessary to reduce the percentage of atropin 
insomuch as in several instances mild atropin intoxication 
has followed the use of the spray. 

4. By concussion of the spines of the 4th and 5th cer- 
vical vertebrae and by sinusoidalization of the same spines. 
This will be discussed under the treatment of asthma. 

On page 297 reference was made to the cotton test in 
asthma. Here reference will be made to another test in 
support of the spasmo-paralytic theory of asthma. By con- 
cussing the spines of the dorsal vertebrae (3rd to the 8th), 
one may provoke a decided lung reflex of dilatation and in 
one predisposed to asthma, an attack or symptoms of an 
attack (dyspnea, constriction about the chest) may be 
provoked. If now, the spines of the 4th and 5th cervical 
vertebrae are concussed, the attack, or the symptoms, may 
be temporarily inhibited. In the first manoeuver the lung 
reflex of dilatation brought the circular muscular fibers into 
action and in the second manoeuver the action of the circular 

310 



Mronchial Asthma 

^■■■■BVBaBB&BaBBaBBE^BSBSCBBSSBSSBBBBSBSXBBaBBBBSS^B&BSBIBSBSS 

* 

£beis was inhibited by contraction of the longitudinal 
:fibeis. 

5. By the tracheal traction test}^ During the time the 
head is thrown forcibly backward, the normal resonance 
obtained by percussion over the manubrium, the anterior 
chest and the lower lobes of the lungs posteriorly, becomes 
translated into a dull or flat sound. This manoeuver is 
called the tracheal traction test by the author and is similar 
to another vago-visceral reflex described elsewhere (page 
321). This test is positive in health and in all cardio- 
pulmonary affections, but it is negative in all cases of idio- 
pathic asthma. This test is present in the interparoxysmal 
asthmatic periods of asthma, and is thus of value in the 
differential diagnosis of other spasmodic affections which 
suggest an asthmatic genesis. Tracheal traction evokes 
contraction of the bronchial muscle by stimulation of the 
bronchoconstrictor nerves in the vagus. In asthma the 
tone of the bronchial muscle is so reduced that it no longer 
responds to vagus stimulation when the neck is forcibly 
extended on the sternum; hence the test is negative in 
asthma. The dull sound supplanting the resonance in the 
normal subject by tracheal traction is due to contraction of 
the bronchial muscle, which puts the air in the trachea and 
bronchi under considerable tension. 

There is another affection closely related to asthma 
which the author has called spasmodic bronchostenosis, 
and in which, like asthma, the tracheal traction test is nega- 
tive. Patients with bronchospasm suffer from a persistent 
spasmodic cough, with or without expectoration, in other 
words, spasmodic bronchostenosis is asthma without par- 
oxysms. 

Many physicians have encountered persistent spasmodic 
coughs in subjects with bronchitis and have no doubt com- 

311 



mented on the intractability of the cases. In such instance^^ 
a bronckospasm complicates the disease. Here climat:::^ 
yields immediate results. The patients often lose theS^^ 
spasmodic cough at once if sent to another climate. He»-» 
the spray described on page 310 is very efficient in corj- 
trolling the spasmodic cough, and the same may be said of 
the smoke from various antispasmodic agents. The following 
formula, which owes its efficacy to pyridin, may be used: 



Powdered stramonium 

Powdered belladonna 

Powdered hyoscyamus 

Powdered potassium nitrate aa i oz. 

M.S. — Burn one-half teaspoonful or more and inhale 
fumes. 



I 



6. The picture of an asthmatic paroxysm suggests the 
spasmo-paralytic theory. The lungs are in an acute em- 
physematous condition, and the dyspnea is expiratory' in 
character. The moment the spasm is relaxed by appropriate 
treatment, the lung reflex of contraction is provoked. 

The table on page 212 gives the differential diagnosis of 
cardiac and bronchial asthma. 

TREATMENT OF BRONCHIAL ASTHMA. 

An attack of asthma may be jugulated by any manoeuver 
which will promote the expiratory phase of respiration or 
which will induce the lung reflex of contraction. The author 
recalls a patient seen in consultation, whose asthmatic 
paroxysm was of two days' duration despite complete 
anesthetization with chloroform and recourse to the con- 
ventional methods yet, a few minutes rhythmical compression 
of the chest during expiration sufficed to control the attack. 
This simple method has been used with success in other cases. 

As before remarked, the lung reflex of contraction can 
312 



£ r n c h i a I Asthma 

1)6 provoked by concussion of the spines of the 4th and 5th 
cervical vertebrae and, in the absence of a hammer and 
pleximeter, the hands may be used (Fig. 3). The latter ma- 
Doeuver often succeeds in arresting a paroxysm, but it may 
be necessary to repeat it several times- In the treatment 
of asthma, one frequently observes astonishing cures reported 
by the rhinologist and other specialists. Here the source 
of irritation (asthmogenic point) is removed, but the en- 
feebled condition of the bronchial musculature is uncorrected 
and any other irritant may be operative in provoking an 
attack. 

In the following method of treatment suggested by the 
author, an attempt is made to increase the vigor of the longi- 
tudinal fibers of the bronchial musculature with the object 
of inducing the lung reflex of contraction. This is best 
eflfected by a strong sinusoidal current — one electrode over 
the spines of the 4th and 5th cervical vertebrae and the other 
electrode over the sacrum. The treatment must be executed 
daily and each stance may last from fifteen minutes to one 
hour. Very often an interrupting electrode at the cervical 
region may be advantageously employed with the object of 
exciting more vigorously the bronchoconstrictor fibers of the 
vagus. All sinusoidal machines are not equally eflficient, 
and to test the latter one electrode is placed over the spines 
of the 4th and 5th cervical vertebrae in a normal subject 
and the other electrode over the sacrum. If the former 
limg-resonance is converted into dullness, after a few minutes 
action of the current, the latter is efficient, and its efficiency 
is always in proportion to the degree of lung-contraction 
which it provokes. This method of treatment will often 
yield phenomenal results even in cases of asthma of many 
years' duration. 

Until the bronchial musculature is strengthened, the 

313 



S p 



n 



d V / 



r a p y 



attacks of asthma will continue (with less violence) and to 
combat the attacks, the nasal spray (page 310) may be 
used. 

Adrenalin chlorid is one of the most efficient agents in 
inhibiting an attack of asthma, and the author emploj-s it 
in doses of from eight to fifteen minims hypodermatically. 
The action of this drug is to provoke the lung refiex o[_ 
contraction and, when effective In asthma, the previo 




Fig. Sl.^Arrangcmenl of bottles for promoting lung-contractioa. 

resonant percussion tone of the lungs is converted into i 
dull or flat sound. Like action on the percussion sound is 
observed In the normal subject. 

In addition to slnusoldahzation as suggested, the patient 
should be instructed to execute respiratory exercises at least 
twice daily with the object of increasing the expiratory' force. 
The latter is best attained by e.xtinguishing with the breath 
the flame of a candle; the distance of the latter from the 
patient Is gradually increased. At first, the effort of blowing 
may provoke asthmatic symptoms, but gradually the latter 
yield. The latter method may even be employed in arresting 
an asthmatic paroxysm. 

314 



H 



m 



Another efl&cient method of promoting the muscles of 

expiration is to instruct the patient to practice daily for a 

definite time, to blow water by air-pressure from one bottle 

to another. Each bottle should hold, at least, a gallon, and 

by the arrangement of tubes, as in the Wolff bottle, the force 

of expiration will transfer the water from one bottle to 

another (Fig. 82). Osier and others claim that the method 

just cited will expand the lungs, but the author has shown 

that the effect is to contract the lungs. 

Emphysema is an affection associated with enfeeblement 
of the longitudinal fibers of the bronchial musculature. 
Here sinusoidalization as suggested in the treatment of 
asthma (page 313) is often very eflficient in the treatment of 
emphysema provided, one can elicit the lung reflex of con- 
traction (dullness of the lungs on percussion) even in a 
moderate degree. 

Tuberculosis is associated with a too voluminous lung 
and the lungs are practically in an emphysematous condition. 
The lungs always show deficient expiratory force. Here 
the bronchial musculature may be brought to contraction 
by sinusoidalization as in the treatment of asthma (page 313). 
Hemoptysis may yield to posture (page 293) and the 
inhalation of amyl nitrite carried to its physiologic effects 
after cocainization of the nose. This is the most efficient 
drug we possess in arresting hemorrhage of the lungs. 
Unless it is efficient after the first inhalation, it is usually 
without any action. The blood-vessels of the lungs have 
novaso-motor nerves and any constriction of the blood- 
vessels must be effected by provoking the lung reflex of 
contraction. Cocainizing the nose increases the efficacy of 
the inhalations. Whereas, amyl nitrite may effect its object 
without the previous use of cocain, the latter drug increases 
its efficacy for the reason cited on page 309. 

315 



S p n d y I t h e r a p j 



CHAPTER IX. 

THE DIGESTIVE SYSTEM. 

THE STOMACH — THE STOMACH REFLEXES — ^PERCUSSION OF THE 
STOMACH — TREATMENT OF DISEASES OF THE STOMACH—THE 
INTESTINES — THE INTESTINAL REFLEXES — ^DISEASES OF THE 
INTESTINES — TREATMENT OF CONSTIPATION — ^THE INTESTINAL 
NEUROSES. 

THE STOMACH. 

By means of the movements of the stomach the food is 
mixed with the gastric juice. The motor nerves of the 
stomach are derived from the vagus and sympathetic nerves. 
Fig. 83, after Openchowski, shows the nerves of the mus- 
culature of the stomach. 

THE STOMACH REFLEX OF CONTRACTION." 

This consists of a contraction of the walls of the stomach 
elicited by the following manoeuvers : 

1. Concussion of the Traube area. 

2. Concussion or sinusoidalizadon of the spines of the 
three first lumbar vertebrae. 

3. By eli citation of the vago- visceral reflex. 

4. By pressure in definite paravertebral areas. 

I. The Traube area or space (Fig. 84) is that half- 
moon -shaped space which normally yields on percussion a 
tympanitic sound, owing to the presence of the cardiac end 
of the stomach. It is bounded above and laterally by the 
contiguous borders of the liver, lung and spleen. Fixing 
our pleximeter firmly in the center of the Traube area of 
tympanicity, we strike the pleximeter with a hammer a 
series of vigorous blows, and then proceed to percuss the 

316 



Stomach Reflex of Contraction 



area of Traube. One observes at once that this region 
■which formerly yielded a tympanitic sound now presents on 




Fic. 83. — Nerves of the stomach muacuUture. C, the cerebTum; V, »oiTuu:hi 
MO, medulla; MS, spinal cotd; 5-10, thoracic roots; VRS, right vagus; VS, 
left vagus; ND, dilators of the canlia; NC, constrictois of the catdia; A, 
Auerbach's plexus; S, 5, fibers from the sympathetic plexus; i, sulcus cruri 
atus; a, csrpus striatum; x, corpus quadrigemina; 4, centeis in the spinal 
cotd. The dilator center for the caraia inbibits the movements 1^ the pylorus. 

percussion a dull or even flat sound. The phenomenon thus 
elicited is the stomach reflex of contraction. 

II. Concussion of the spines of the ist, 2nd and 3rd 
lumbar vertebrae will also produce the stomach reflex of 
contraction. 

III. Vide percussion of the stomach, page 321. 

317 



S P 



d y I t h e 



a P y 



IV. Firm and deep pressure with the thumb a 
of the spines of the first three lumbar vertebrae on the left 
side will also elicit the reflex in question. 

THE STOMACH REFLEX OF DILATATION. 

This reflex, consists of a dilatation of the stomach pro- 
voked by irritation of the skin over the area of Traube, 




T and spleen, and 



after tapping the epigastrium, by deep and firm pressure 
to the left of the spine of the nth dorsal vertebra and by 
concussion or sinusoidalization of the latter spinous process 
(Fig 85). 

Both stomach reflexes may be confirmed by the vago- 
visceral reflex which is described under percussion of the 
stomach. 

31S 



1 m a c h R efl e x of Dilatation 




Pig, 85 — Effects of the inhilBtion of ether on ihe stomach: 
, the lower border ot the stomach before atid (C), after the inhalali 
I illustrating area of gastric tenderness. If a poini of tenderness e 
. shifted Id XI. after eliciting Ihe stomach reflex 
lower bonier of the organ to recede ftom A to B. 



This illustration ii 



L the 

^^H mi 



There is, perliaps, no greater excitant of the stomach 
reflex of dilatation than irritation of the nasal mucosa by 
irritating vapors. The effects of inhaling ether are shown in 
Fig. 85. The reflex in question thus excited is of longer 
duration than any other visceral reflex. In one patient the 
stomach remained dilated for fully eight hours. ChloTOform 
vapor Is less active than ether in provoking the reflex. In 
this reflex the fundus of the stomach likewise dilates and 
the author believes that the asthma from odors is due lo 
pressure of an acutely dilated stomach on the heart. Thus, 
one patient who suffered an asthmatic paroxysm from the 
odor of hay, demonstrated an enormously dilated stomach. 
When the latter was reduced by concussion of the spines 
of the first three lumbar vertebrte, the paroxysm ceased. 
When the nose was previously cocainized, no asthma could 
be provoked from the odor of hay. The efi'ect of insufflation 
of the stomach on the heart Is shown In Fig. 2,:i- 

In the literature, a number of cases of acute dilalatim of 
the stomach have been reported following operations which 
are characterized by sudden onset, symptoms of collapse 
and vomiting of large quantities of fluid. The cause is 
obscure, but the author's Investigations seem to show that 
the dilatation is associated with the irritating action of the 
vapors employed as anesthetics. Here the condition Is a 
reflex due to irritation of probable gastro-dllator fibers In 
the vagus. As the author has shown (page 202) irritating 
vapors will inhibit the heart, but if the nose has been pre- 
viously cocainized such action docs not ensue. He therefore 
suggests the use of cocain in the nose as a routine method 
before employing anesthetics to inhibit the action of the 
vapors on the heart and on the stomach. Fig. 85 shows 
the effects of inhalation of ether (duration of Inhalation, one 
minute) on the stomach. 

320 




ercussion o f t h e Stomach 

It may be noted that concussion of the spines of the first 
three lumbar vertebrae will at once reduce the lower border 
of the stomach to the norm; otherwise the dilatation con- 
tinues for some time. Such concussion may be of service 
in acute dilatation of the stomach following operations. 

PERCUSSION OF THE STOMACH. 

No gastrologist can lay any claim to distinction in his 
chosen speciality until he has devised some original method 
for percussing the stomach, and the result has been a number 
of complicated and, in some instances, faulty methods of 
examination. The author contends that any physician who 
is able to appreciate percussion -sounds can accurately 
percuss not only the lower border of the stomach, but the 
upper border of the organ as weU (Fig. 86) by the following 
simple method which elicits the vago-visceral reflex of 
stomach -contraction . 

By directing the patient to draw the head slowly back- 
waid, though forcibly, thus inducing hypertension of the 
cervical muscles, the pneumogastric nerves are stimulated 
and this stimulation is manifested clinically : 

1. By inhibition of the heart (page 228). 

2. By the tracheal traction test (page 311). 

3. By the stomach reflex of contraction. 

To obtain the latter reflex, the borders of the stomach 
are percussed during the time the patient forcibly extends 
his head as far back as possible. When he is unable to do this 
satisfactorily, an assistant may do it for him. During the 
time tension of the muscles of the neck is maintained, the 
stomach yields a dullness on light percussion with the patient 
standing.* 

^The dullness is accentuated if an assistant compresses the spinal column during 
percussion (page 80). 

321 



S p 



I 



a p y 



To explain the altered percussion sound in the stomach 
reflex of contraction, one must have recourse to the Skodaic 
interpretation of the condition which exists when dullness 
supplants tympanic! ty. In the stomach reflex of contraction, 
the gastric walls become tense, thus putting the air or gas 
within them under increased tension, and, for this reason, 
we have the physical elements necessary for the transiliqn 
of a tympanitic to a dull sound. 




Fig. 86,— Percussion of the stomach by airl of the vago-visceral n 

head to be fined OS shown in Fig. 65), The illustration with tiw dotted line indlcaMf 
an increased area of the oigan after irritation of the skin of Traube's area. Thr 
other iJltuiration demonstrates the oultine of the stomach in a case of gastroptosis. 



Reference to Fig. 5 shows that concussion of the spines 
of the first three lumbar vertebrae is not available for per- 
cussion. WWle the latter manocuver is advantageous in 
treatment, it also provokes the intestinal reflex of contraction 
and as the latter yields a dullness on percussion, the dullness 
of this reflex cannot be differentiated from the dullness of 
the stomach reflex of contraction. 

THE STOMACH REFLEX OF CONTRACTION IN DIAGNOSIS. 

Reference has already been made to the value of this 
reflex in percussion of the stomach. 



S t m a c h'Dis location 

It remains to consider its value in determining the motor 
power of the organ and the localization of pain. 

Having determined the lower border of the organ by aid 
of the vago-visceral reflex, we concuss rather forcibly the 
area of Traube and note the difference of the lower border 
before and after such concussion. Naturally, the head must 
be maintained properly during the time percussion of the 
stomach is executed. It will be noted in Fig. 85, that the 
lower border of the stomach shifts from A to B, which 
represents the degree of the stomach contraction which is in 
direct ratio to the motor power of the organ. In the norm 
the degree of recession of the lower border of the stomach 
varies from 2 to 4 cm. 

Let one assume that the patient has a fixed point of 
sensitiveness in the epigastrium and it is a question whether 
this area of tenderness is or is not associated with the stomach. 
In the former event, concussion of the area of Traube by 
causing contraction of the stomach, will shift the area of 
tenderness from Xi to X2 (Fig. 85). Within a minute, 
however (the duration of the reflex), the area of tenderness 
will again be located at Xi*. 

The presence of a growth and its association with the 
stomach may be shown to exist by aid of the stomach reflex, 
for elicitation of the latter will cause a dislocation of the 
growth upward and to the left. Eliciting the stomach 
reflex of dilatation (concussion of the spine of the nth 
dorsal vertebra) will cause an area of tenderness or a growth 
to be dislocated downward. 

*The author suggests this manoeuver in the differential diagnosis of a gastric and 
duodenal ulcer. The employment of this manoeuver will not cause a dis- 
locatioii of the area of tenderness on palpation if the ulcer is duodenal. 



323 



TREATMENT. 

Motor-insufficiency, or lack of power of the muscular 
wall of the stomach to discharge its contents, results from 
many causes, notably the burden thrown upon it by in- 
discreet eating. This insufficiency of the oi^an, which 
practically always eventuates in dilatation of the stomach 
(gastrectasis), is usually regarded as a dyspepsia, insomuch 
as the symptoms are dyspeptic in character. Many so-called 
neuroses of the stomach are dependent on the same cause. 
The author realizes that he gives expression to heterodoxic 
views when he attempts a classification of all diseases of the 
stomach into two main classes: organic and functional. To 
the former belong chiefly ulcers and tumors, whereas, the 
latter are not diseases but merely symptoms. In his early 
professional career, the author religiously executed the 
conventional gastric analyses, and while he was able to 
determine anomalies in the gastric secretion, he rarely 
succeeded in curing his patients; he was successful as a 
diagnostician and a failure as a therapeutist. The moment 
he departed from traditional lines and sought a constitutional 
cause for the symptomatic affections of the stomach, he began 
to achieve a modicum of success in the treatment of his 
cases. 

There is an element of nervousness in aU dj^pepsias, 
and this nervousness is maintained by an enervated nervous 
system. In all instances of functional diseases of the stomach, 
treatment must be addressed to an enfeebled nervous 
system ; this is essentially the basis of gastrotherapy. 

In the experience of the author, the most constant con- 
dition identified with functional diseases of the stomach is 
an insufficiency of the muscular walls with a moderate 
dilatation of the organ and the relief of this conditior 



The Intestine 

is possible after the manner to be cited, is of greater value 
than any other symptomatic method of treatment. 

To contract the stomach and to augment the tone of its 
musculature two methods are available: i. By aid of the 
sinusoidal current; one electrode over the space of Traube 
and the other over the spines of the first three lumbar 
vertebrae. 2. By concussion of the spines of the first three 
lumbar vertebrae. Treatment by either method must be 
executed daily and each stance should, at least, last fifteen 
minutes. 

In gastric or intestinal tympanites, concussion of the 
spines of the first three lumbar vertebrae to elicit the stomach 
and intestinal reflexes is a very effective method. 

THE INTESTINE. 

The movements of the intestine are controlled by the 
central nervous system and the small intestine receives its 
efferent nerves through the vagus and the splanchnic. 
Respecting the action of these nerves there is no unanimity 
of opinion. It may be remarked, however, that vagus- 
stimulation by contraction of the muscles of the neck (page 
228) while it influences the heart, bronchi and stomach, is 
absolutely without any influence on the percussion sound of 
the intestine. 

THE INTESTINAL REFLEX OF CONTRACTION. 

This reflex consists of a contraction of the intestine and 
is evidenced by dullness on percussion supplanting the 
tympanitic tone prior to the elicitation of the manceuver. 
Of all the visceral reflexes described by the author, this 
particular reflex is of longest duration. In some individuals 
it may persist for five or more minutes, and it is more evident 
and longer in duration in children than in adults. It is 

325 



best elicited by concussion or sinusoidalization of the spines 
of the first three lumbar vertcbrfe. Firm and deep pressure 
alongside of the spines of the first three lumbar vertebra; 
(Fig. 48) will also evoke this reflex; pressure on the righl 
side of the spines in question will contract the intestine 
only on the right side, whereas pressure on the left side 
will only influence the intestine on that side. 

Concussion of the spines in question, however, evokes 
contraction of the intestine on both sides. 



THE INTESTINAL REFLEX OF DILATATION. 
This reflex consists of a dilatation of the intestine and 
may be elicited in one of the following ways: 

1. By irritation of the skin of the abdomen. Here the 
intestinal dilatation is very circumscribed and practically 
limited to the area of cutaneous irritation. 

2. By firm and deep pressure at the side of the spine 
of the nth dorsal vertebra. Here the intestinal dilatation 
is limited to either the entire right or left side of the abdomen 
dependent on the side subjected to pressure. 

3. By concussion or sinusoidalization of the spine of the 
1 1 th dorsal vertebra. Concussion is more potent than 
sinusoidalization in discharging this reflex. Here the intes- 
tinal dilatation involves all of the intestine. The reflex of 
dilatation is less pronounced and of shorter duration thj 
its counter-reflex of contraction. 



DISEASES OF THE INTESTINES. 



1 



It is generally conceded by the gastro-enterologist that 
in intestinal and gastric diseases, the chemical or digestive 
functions are subservient to the more important motor 
functions. In the functional intestinal diseases, one again 
notes muscles in antagonism (page i:). and the anoni 
326 



onsttpatt n 

in function is expressed by the predominant ax:tion of either 
the longitudinal or circular muscular fibers. The movements 
of the intestines as revealed to us by the physiologist are of 
little or no clinical value. The chief form of intestinal 
movement is known as peristalsis. The peristaltic move- 
ment is essentially a constriction of the intestinal wall, com- 
mencing at a definite point and passes downward from 
segment to segment, whereas the parts behind the advancing 
zone of constriction relax slowly. The physiologist does 
not account for the action of the longitudinal fibers in 
peristalsis, but assumes that, insomuch as constriction is the 
attribute of the circular layer of muscles, the latter layer is 
the chief factor in peristalsis. 

CONSTIPATION. 

In one class of patients, constipation may exist without 
any symptoms, whereas others complain of headache, 
anorexia, lassitude, mental depression, etc. The latter 
symptoms have been dignified by the term copremia^ which 
is supposed to indicate fecal poisoning. The fetich of many 
neurasthenics is the water-closet, and the elysium of others 
is a purgative. It is easier to take a simple pill than to 
pursue a prolix dietetic regime, hence the prestige of the 
purgative habit. 

What constitutes constipation? We do not, as a rule, 
seek to analyze this question, and content ourselves with the 
bare statement of the patient. Grant suggests the following 
test for constipation : The patient is given a tablespoonful 
of animal charcoal. Normally it appears in the stools in 
twenty-four hours. By this means, even though the patient 
affirms that he is or is not constipated, the charcoal test will 
decide the question. Dr. C. M. Cooper of San Francisco, 
resorts to the following test to determine the origin of 

327 



Spondylotherapy 

constipation. The test is based on the fact that, in the norm, 
the passage of charcoal or bismuth (which blacken the feces) 
from the stomach to the rectum is attained in from twelve 
to forty-eight hours. If more than seventy -two hours elapse 
before colored feces are detected in the rectum, constipation 
is present. Hert^, of London, has shown that, if after the 
lapse of forty-eight hours the rectum is empty, or, as Cooper 
shows, if the sigmoidoscope demonstrates the presence of 
blackened feces lodged in the sigmoid, there is some retarda- 
tion from the middle of the transverse colon. If the feces 
lodge in the rectum longer than twenty -four hours, then the 
constipation is rectal in origin, dependent on one of the 
following causes: Loss of the reflex of defecation from 
anesthesia or neglect (indolence, false pride, pain of fissures 
or hemorrhoids), atony or paresis of the rectum and weak- 
ness of the voluntary muscles of defecation. 

One must differentiate two forms of constipation : atonic 
and spastic. In some instances the latter are combined. 

Atonic constipation is recognized by the dilated 
intestines which cause a protuberance of the abdomen and 
percussion of the latter yields a tympanitic sound. Here, 
concussion of the spines of the first three lumbar vertebrae, 
fails to yield as in the norm a decided intestinal reflex of 
contraction as revealed by the dull percussion note. Not 
only are we thus able objectively to determine this form of 
constipation, but can also say what part of fhe bowel is 
implicated. Very often the dullness is obtained only over 
the ascending or descending colon, showing that wherever 
dullness is obtained, that portion of the intestinal canal is 
not involved in atonic constipation. 

Spastic constipation is less frequent than the atonic 
form. The former is caused by a tonic contraction of in- 
testinal segments which hold back fecal masses, whereas 

328 



Treatment of Constipation 



BOB 



the latter is dependent on an inherent enfeeblement of the 
intestinal musculature. There is always a feeling in the 
spastic form as if the evacuation were unsatisfactory. The 
patients press a great deal at stool and evacuate long, thin 
and flattened fecal masses. 

On palpation of the abdomen one may detect localized 
contractions, especially of the transverse colon {corde colique). 
The implicated intestinal segment may be rolled under the 
finger like a cord. Percussion over the spastic intestinal 
areas )rields a dull in lieu of a tympanitic sound. Normally, 
when one scratches the abdominal skin over a dull intestinal 
area, or by a few blows directed against the epigastriimi, the 
dullness becomes tympanitic, owing to temporary dilatation 
of the intestine (intestinal reflex of dilatation). The per- 
cussion sound of the spastic intestine does not change. As 
a rule, the spastic form does not lead to meteorism, yet in 
rare instances, there may be symptoms corresponding to 
ileus and even celiotomy has been performed by mistake. 

In the spastic form not only are cathartics useless, but 
they accentuate the symptoms. When olive oil is effective 
in constipation in tablespoonful doses one-half hour before 
each meal, it is almost diagnostic of the spastic form of 
constipation. 

TREATMENT OF CONSTIPATION. 

Whatever treatment is employed in this condition, one 
must always conciliate a psychic factor. The psychic factor 
takes into consideration the fact that the desire to go to 
stool is a habit. Habit in itself is a great economizer of 
nerve-force, for it is automatic in action and reduces cerebral 
participation to a minimum. 

Thought directed toward a part will increase its functional 
activity. The mental state influences the intestinal canal 

329 



S p on d y I t h e r a p y 

and one may recall the frequency of nervous diarrhoa. 
The diarrhoea of students before an examination, of nervous 
women and men during transient periods of excitement, etc., 
is of this nature. Canstatt tells of a surgeon who had an 
attack of diarrhoea before every important operation. 

From what has preceded, the treatment of atonic con- 
stipation consists in methods which have for their object the 
elicitation of the intestinal reflex of contraction. In the 
experience of the author, the latter is best elicited by sinu- 
soidalization or concussion of the spines of the first three 
lumbar vertebrae. Concussion appears to be more eflFective 
in the treatment of atonic constipation. If the sinusoidal 
current is employed, one electrode is fixed over the sacrum 
and the other over the spines of the first three limibar 
vertebrae. Strong currents must be used and the daily stances 
should last fully fifteen minutes. Within a week, usually, 
the treatment is effective, but must be continued thereafter 
less often. 

Spastic constipation is remedied by the method for 
eliciting the intestinal reflex of dilatation, viz.^ sinusoidaliza- 
tion or concussion of the spine of the nth dorsal vertebra. 

When neither form of constipation preddminates, sinu- 
soidalization or concussion at the same stance may alternate 
between the spine of the nth dorsal vertebra to stimulate 
the longitudinal muscular fibers and the spines of the first 
three lumbar vertebrae to excite contraction of the circular 
fibers of the intestines. 

INTESTINAL NEUROSES. 

Among the motor neuroses favorably influenced by the 
methods suggested in this work are the following : 

I. Nervous diarrhoea. — This condition presumes an 
absence of all anatomic changes in the intestinal wall. The 

330 



ver-Reflexes 

subjects are usually neuropaths. The treatment consists of 
alternate toning of the circular (concussion or sinusoidaliza- 
tion of the spines of the first three lumbar vertebrae) and 
longitudinal muscular fibers of the intestines (spine of the 
nth dorsal vertebra). 

2. Peristaltic unrest. — In this condition (tormina 
ifUestinarum) patients suffer from loud noises, which may 

' often be heard by others. The peristaltic movements may 
be so loud as to interfere with sleep. The movements are 
often visible and may be palpated. The same treatment 
may be used as indicated in nervous diarrhoea. 

3. Enterospasm. — In this condition the intestinal 
spasticity may be limited or diffused, and in the latter 
instance the abdomen is retracted. 

Enteralgia is quite independent of the colicky pains 
observed in enterospasm and is caused by a tetanic contrac- 
tion of the enteric musculature. The treatment in both 
affections consists of relaxing the spasm by concussion or 
sinusoidalization of the spine of the nth dorsal vertebra. 

4. Nervous constipation. — This is frequently asso- 
ciated with atony of the intestines and the subjects are 
usually hysterical and suffer paroxysmally from meteorism. 
There is always a tendency to meteorism whenever there is 
any weakness of the intestinal musculature. The treatment 
of this condition is similar to that described under nervous 
diarrhoea. 

THE liver. 

There are two liver reflexes : that of contraction and 
that of dilatation. The liver reflex of contraction may be 
elicited in three ways : 

1. By irritation of the skin over the liver. 

2, By fixing a pleximeter anywhere in the hepatic region 

331 



S p n d y I t h 



r a p y 



and striking the ple.ximttcr a scries of vigorous blowi wiih 
a hammer. 

3. By concussion or sinusoidalization of the spine? of 
the first three lumbar vertebne. 

The latter manccuver is the most effective. By any ol 
the foregoing methods, percussion demonstrates (Fig. 87) 
a contraction of the liver. In percussing the lower border , 



kct 


^ 


H 


Itt. 


1 


■r 


m 



Fir.. 87.— DemoiiEtralLngthelivvr iclUx <jf lomrniion. The conlim 
rcprcSERI the bordera of ihc organ befcire and the inlt^rruplpd lines the borders after 
eliciting ihe liver reflex of contraction. The latter reflex in this patient was diciled 
by concussion of the spines of the first three lumbar vertebne. The livet in the 
iiiaminai7 line measured 13 cm. &nd wu reduced lo 7 cm. 



of the liver, the dullness of the lower border of the organ is 
facilitated by inclining the b(xly backwards or by having an 
assistant fix the hand upon the spinal column to prevent 
vibrations of the latter (Page 80). 

The liver rcfiex of dUaiaiion is evidenced by an enlarge- 
ment of the organ subsequent to the execution of the following 



manoeuvers ; 



332 



A 



TYTc^rWyst o logy of Li 



1. By deep and firm pressure with the finger to the 
right of the spinous process of the nth dorsal vertebra 
(Fig. 48). 

2. By sinusoidalization or concussion of the spine of 
the r 1 th dorsal vertebra. This is the more effective of the 
two methods. 




ating tnlargement of ihe liver by concussion of the spine 1 
e" nth dorsal vertebra. The continuous lines represent Ihe area of dullne 
before, and the intemipled lines (he area after eliriiing the liver reflex of dilataiioi 
The liver ia the mammarv line measured 11 cm. and was increased to t6 cm. 



^^B PATHOLOGIC PHYSIOLOGY. 

^^^Circtdatory Disturbances. — During digestion there is a 
^^^ysiologic congestion of the liver, but in persons who eat 
and drink to excess, this congestion may become pathologic 
and may even conduce to organic change. The fullness or 
distress in the right hypochondrium, to which reference is 
frequently made by dyspeptics, may be caused as Osier 
suggests, by hyperemia of the liver. The amount of blood 
contained in the liver is equivalent to one-fourth the amount 
3.13 



S p 



n 



t h 



a p y 



of blood contained in the body. During digestion this 
amount is very mucli increased, hence the dro«'siness alter 
eating, especially in dyspeptics, the result of brain-anemia 
from portal congestion and the cold extremities and chilly 
sensations. Hyperemia of the organs has been noted in 
suppression of the menses. Passive congestion is frequent 
in all conditions leading to venous stasis in the right ventricle 
of the heart, and is associated with swelling of the organ. 

Hepatic toxemia. — Any hepatic disease may be associ- 
ated with a variety of toxic symptoms connected with the 
nervous system. 

In the norm, the poisonous substances in the intestinal 
canal are either not absorbed or, if they are, they are made 
Innocuous and rapidly excreted. Auto-protection of the 
organism against self-poisoning is achieved by organs which 
either arrest or transform the poisons or eliminate them. 

The organs of defense practically represent the bodily 
resistance. This, equationally expressed for germ-infection, 
is applicable to auto-poisoning, viz.: 



PTA 



D, the disease, equals P, the poison, multiplied by T, 
its toxicity, multiplied by A, its amounl, the product 
being R, the resistance of the individual attacked. The 
liver is unquesdonably the chief organ of defense. It 
converts the poisons into non-toxic and assimilable sub- 
stances, Alters them, and excretes them in the bile. When 
the liver-fimction becomes insufficient, the poisons des- 
tined for destruction enter the blood, and the clinical 
picture of hepatic toxemia results. If the liver is ex- 
cluded from the general circulation by connecting the 
portal vein with the inferior vena cava, nervous manifes- 
tations and even death may follow the ingestion of meat. 
The condition known as autointoxUatUm is, practically 
speaking, an hepatic toxemia. 
334 



I 



In testinal Autointoxication 

Intestinal autointoxication, as we now comprehend it, 
may be briefly summarized as follows: During digestion, 
a number of poisons or enterotoxins are manufactured as a 
result of putrefaction of albuminoid food in the intestines. 
These enterotoxins attain the liver by way of the entero- 
hepatic circulation where they are made innocuous. From 
the liver they pass into the general circulation and are excreted 
in the urine. If albimiinoid putrefaction is excessive, or if the 
liver and kidneys (notably the former), prove inadequate in 
either neutralizing or excreting the poisons, autointoxication 
ensues. Intoxication is expressed by a motley group of 
symptoms, which often parade under the equivocal designa- 
tion, neurasthenia. Now, this conception of intestinal 
autointoxication is only partially correct. While the usual 
enterotoxins are bacterial products, there are also poisonous 
albumoses, i. e., intermediate products manufactured in the 
digestion of albuminous foodstuffs. It is well known that 
when peptones and albumoses (normal products of digestion) 
are injected directiy into the blood, they are poisonous and 
even fatal in their effects. Falloise has recently had an 
excellent opportunity of studying this subject in a patient 
with a fistula of the small intestine. He concludes that 
albuminoid-putrefaction is not the only process concerned 
in autointoxication, and that an aqueous extract of the con- 
tents of the small intestine is infinitely more toxic than an 
extract made from the contents of the large intestine. 
Hence, if we accept the prevailing opinion that putrefaction 
of tiie albuminous molecule is limited in the norm to the 
large intestine, factors other than putrefaction of the albu- 
minous molecule must be concerned in intestinal autointoxi- 
cation. 

Contrary to current belief, I have found that, in those 
suffering from self-poisoning, diarrhoea, or at any rate, 

335 



looseness of the bowels prevails rather than constipation, 
and it appears as if this were a compensatory attempt on 
the part of the organism to rid itself of noxious produds. 
Strassburger has shown that retarded bowel-action rather 
indicates diminished products of decomposition which norm- 
ally stimulate the action of the intestines. If one were 
guided in the diagnosis of autointoxication by the statements 
of the patient, the condition would rarely be recognized. 
The fact is. the patients infrequently complain of symptoms 
of indigestion. It is only in aggravated cases that one 
encounters the conventional symptoms of dyspepsia. In 
most instances, nervous symptoms precede the local signs 
of indigestion. 

Another supposed classical symptom of the affection is 
indicanuria; yet my ex-perience shows that it is comparatively 
infrequent. 

If one electrode of a sinusoidal current is placed over the 
sacrum and the other over the spines of the first three 
lumbar vertebrae, or, if the spines in question are concussed, 
one evokes the liver reflex of contraction. Either manoeuver 
will promote the excretion of indican in the urine and its 
presence in the urine may be demonstrated after a single 
stance lasting fifteen minutes, even though previously absent. 
Naturally the urine must be voided before and after the 
application of the current and the specimens compared after 
examination is made for indican. For the examination of 
the latter I prefer the simple test recommended by Porter: 

Add in a test-tube equal quantities of urine and 
cbemically pure hydrochloric acid. To this mixture add 
three drops of a one-half per cent solution of potassium 
permanganate. If indican is present in the urine there 
wilj be formed a purplijh cloud in the fluid in the test- 
tube. Then add a few drops of chloroform then one drop 
33b 



In t es tin a I Autointoxication 

more. of the potash solution and a few drops more of 
chloroform and shake vigorously. The deep-blue color 
resulting is due to precipitation of indican by chloroform 
and the amount and intensity of the precipitated indican 
determine the extent of the putrefactive changes going 
on in the alimentary tract. 

Splanchnic neurasthenia. — In his book on this 
subject, the author has described a condition dependent on 
intraabdominal venous congestion superinduced by in- 
sufl&ciency of the splanchnic vaso-motor mechanism, and 
that the neurasthenic symptoms resulting therefrom may be 
corrected by relief of the congestion and by manceuvers 
which will increase the efficiency of the liver as an organ of 
defense. The fact is, splanchnic neurasthenia is intimately 
associated with autointoxication. When this venous con- 
gestion exists it interferes with a proper supply of arterial 
blood, and in consequence, the tissues and organs are bathed 
in pools of stagnant blood — they are practically asph)rxiated. 
Again, the impeded circulation cannot remove the toxic 
products of digestion, and instead of the latter being at once 
conveyed to organs of elimination like the kidneys, they are 
arrested or transformed by organs like the liver, which soon 
prove inadequate to discharge their anti -toxic function; then 
we have the creation of symptoms which belong to the 
category of self -poisoning. 

treatment. 

Circulatory disturbances. — Every condition conduc- 
ing to a stagnation of blood in the right heart is eventually 
followed by passive congestion of the liver. Merklen and 
Heitz have shown that coincident with the cHcitation of the 
heart reflex, there is a reduction in the size of the liver 
(Fig. 58). Here, the heart momentarily awakens from its 
lethargy and by pumping an augmented quantity of blood 

337 



S p n d y I Q 



into the circulation temporarily reduces the congestion of 
the iiver. 

Many Anglo-Indian physicians directly aspirate eighteen 
or more ounces of blood directly from the liver and it is 
claimed that excellent results ensue from this hepato-phle- 
botomy. This method was suggested by observing the 
reduction in the volume of the liver after bleeding from piles. 

Now, in many instances, one may regard congestion of 
the liver as a process of compensation, the liver acting as a 
reservoir for the redundant blood which correspondingly 
reduces the work of the heart. 

By enlarging the volume of the liver by concussion of the 
spine of the nth dorsal vertebra, the patient may be bled 
into his own vessels for, even in the norm, this organ contains 
approximately one-fourth of the amount of blood in the body. 

In other instances, the organ may be depleted by exciting 
the liver reflex of contraction by sinusoidalization or con- 
cussion of the spinous processes of the first three lumbar 
vertebras. 

Intestinal autointoxication. — Food as a factor in 
the treatment of autointoxication is a much-abused com- 
modity. Someone has observed that the ultimate trend of 
the physician was to prove that even food was poisonous and 
what has been suggested as a facetious prognostication, 
appears to have been endowed with reality, when one 
seriously contemplates the endeavors of dietetic revolution- 
ists. Many dietetic vagaries are as consistent as the per- 
fervid plea of the poet Shelley, who wanted us to become 
vegetarians and marry our sisters. By opposing aHmentary 
insufficiency we possess a formidable weapon in immunizing 
the tissues against interminable dietetic insults. One must 
not forget that there is such a condition as "indigestion 
toxemia," due either to an excessive production of poise 
338 



Intestinal Autointoxication 

or to enfeeblement of the defenses. Thus there is an hepatic 
as well as a gastric and intestinal dyspepsia and the liver 
dare not be ignored even in the treatment of an aihnent so 
plebeian as dyspepsia. 

Intestinal asepsis is, in my experience, a purely theoretic 
conception which is rarely realized in practice. Intestinal 
antisepsis is difficult, if not impossible, for the following 
reasons: i. An antiseptic strong enough to destroy germs 
is equally destructive to the intestinal mucosa. 2. Germicides 
will destroy the innocent germs which are concerned in 
digestion. 3. Germicides are rapidly absorbed or are made 
chemically inert. Recourse is also had to purgatives, but 
they often accentuate the symptoms of autointoxication 
because they concentrate the poisons already absorbed and 
remove the intestinal epithelium and mucus which practically 
act as barriers against the absorption of enterotoxins. We 
have discarded the swab in infectious diseases of the throat, 
for the reason that it mechanically injures the membrane of 
the throat and thus opens up new portals of infection. In 
this sense, the purgative is essentially an intestinal swab. 

Intestinal autointoxication is a misnomer; the term of 
qualification refers only to the site where the poisons are 
manufactured. 

The offending viscus in autointoxication is usually the 
liver and, if this organ is made equal to the task of destroying 
the poisons, the subject of self -poisoning would be simplified. 

In autointoxication the liver is congested, enlarged and 
extremely sensitive to pressure ; in fact, when the latter signs 
are present in the absence of organic disease, we are in the 
possession of the most positive evidence of hepatic inade- 
quacy. Reference has already been made to the increased 
excretion of indican following the elicitation of the liver 
reflex of contraction (page 336) and the manoeuver for 

339 



exciting the latter is the method employed by the autho^i^ | 
in correcting hepatic inadequacy in autointoxication. Tcz=3 
best elicit the reflex in question sinusoidalization or concus- - 
sion of the spines of the first three lumbar vertebne i — s 
executed daily. 

The results even after a single treatment is evident ; thi^ ■ 
liver is reduced in volume and palpation shows diminishecj 
tenderness. 

It would be manifestly inconsistent were the author to . 
contend that the method suggested is curative to the exclusion j 
of other methods of treatment. On the contrary, he is more I 
disposed to say that concussion or sinusoidalization of the 1 
lumbar spines is more effectual as an individual method of 
treatment. 

Excessive albuminous food, that is to say, a diet con- 
taining a large quantity of meats and eggs, augments 
intestinal putrefaction, and even though the organs of 
defense are relatively normal, they are incapable of perform- 
ing their functions when an increased burden is thrust upon 
them. 

It will be necessary for us to briefly consider other 
methods of treatment in autointoxication. Some contend 
that if indican can be detected in the urine, even by a feeble 
reaction, it is an indication that it is excreted in exce^ive 
quantity. Tndican in the urine {indicanuria) suggests bac- 
terial putrefaction of the proteid substances in the intes- 
tines, for in perfect digestion of the proteids, it cannot be 
detected in the urine. 

Intestinal putrefaction as already suggested results from 
the action of proteolytic bacilli on albuminous f(xxl ajid the 
primary indication in treatment is to modify the culture 
medium of the intestine so as to render it inimical to _t|^ 
germs in question. 

340 



Intestinal Autointoxication 

The best and most certain method of treatment is by means of an 
antiputrid regime. 

It has been suggested that a sterile regime will destroy the virulence 
of the bacterial flora of the intestine, but observations show that 
sterile food will diminish but does not completely inhibit intestinal 
putrefaction. 

An aseptic regime is best attained by the avoidance of crude 
vegetables and fruits, for no matter how thoroughly they are washed 
they still remain contaminated. 

The cooking of foods will diminish the danger of infection by 
destroying bacterial growths and larger parasites (tapeworms and 
trichinae). The cooking of vegetable foods breaks up the starch 
grains, bursting the cellulose and thus permitting the digestive fluids 
to come into immediate contact with the granulose. 

Antiputrid regime. — As before remarked, this is the most 
satisfactory means of antagonizing intestinal putrefaction. The 
putrescent aliments are the proteids and if the latter could be completely 
eliminated, there would be no putrefaction, and consequendy, no 
intestinal autointoxication. All investigations show that intestinal 
putrefaction augments parallel with the quantity of albuminous 
foodstuffs. We know, however, that the proteids or albuminous 
foodstuffs are true tissue-builders and repairers and consequendy 
cannot be eliminated without compromising nutrition. We know, 
furthermore, that the proteid requirements of the individual have been 
exaggerated and that the experiments of Professor Chittenden show 
that men can maintain health and muscular efficiency for long periods 
on about half the amount of proteid which is usually consumed. It 
would be difficult now to maintain, as did Herbert Spencer, that the 
consumers of meat showed superior physical strength to the consumers 
of rice, which would be equivalent to saying the Russians demonstrated 
more physical endurance than the Japanese. One may conclude 
conservatively that we ordinarily consume more proteid food than is 
necessary and that ingested in excess, it is either conserved for future 
uses of the economy, or remaining undigested, it must be reduced by 
bacterial digestion. Instead of the individual requiring one hundred 
and twenty grams daily of proteid according to the diet table of 
Moleschottyor one hundred grams according to the diet table of Ranke, 

341 



S p 



loth 



a p y 



the amount of jirotcld may be reduced considerably without prejudice 
to the Individual. 

If nn Individual were desirous of taking his daily supply (loo 
({ritmN) of j)n>teid in the form of meat, it would be necessary for him 
\n rimNumc a tittle more than one pound (500 grams) of meat. It 
wan nt onr time sup[>OMd that fata exercised no influence on intestinal 
pulrrfni'tion, but more recent experiments have demonstrated that 
thl* olMtTVUtion is faulty and that fata do increase intestinal putre- 
(Kdion. 

The lai'to-farlna<^)US diet of Combe is the antiputrid regime par 
txtMrnrt in the treatment of autointestinal intoxicatioR; it acts not 
by any tIrMrurtive inRuence on the intestinal flora, but seeks only to 
mixlify Ih*- soil in which the microbes live. 

Mli.K. — Of all aliments, milk is probably the most resistant to 
(lUlrrfKclion, and it has been found by Wintemitz that if a certain 
(luanltty vi milk is given with a meat diet, it will diminish the pro- 
ttuolUin itf rntrroltutins. Milk owes its antiputrid properties lo the 
Ucliwr which it i-ontains and which, under the influence of the aerobic 
banlU vA Ihr small intestine (rofi and taetis aerogmes) is decomposed 
int\> aua'inic and lactic adds. These acids inhibit the action of the 
|tr^i«H4ytic bacilli in the laqce intrstiite from acting on the albuminous 
(tvit^tuAs. Cow's milk contains about 3.5 per cent of proleids 
^v'Mrrty cawim^n) agiinst n.i per cent in the white of eggs and 
ttwut *o jKT I'ent in meats. 

1 6ad that s^tme indi^Sduals cannot tolerate even small quantities 
ot milk ^raw vtr hoilcdl without causing diarThvra. In such instances. 
1 cm)4i'«y UcM«r vwilk su|;art- t\™'s milk .\>nta:n* 5 per oent of 
UcfcMv; hrncv if ttw individual will take about 40c jT^^n^ 01 lactose 
at rax'h ii>e*l. W <riU hare OiHtswiPcd an Mpount fqual h.' abcmi three 



n 1 65 tin a I Autointoxication 



SBBBa 



4. Koumiss. 

5. Kefir. 

6« Fresh cheese (Jromage d la creme). 

Buttermilk, owing to its small amount of fat and casein (chief 
protdd of milk), is a very desirable product in autointoxication, inso- 
much as one knows that these substances favor putrefaction. Again, 
the presence of lactic add and lactose enables the latter to produce 
lactic acid in statu nascenti. Condensed buttermilk may be obtained 
in flasks containing 330 grams, and to prepare the buttermilk one 
mixes the contents of one flask with 660 grams of a decoction of cereals, 
thus obtaining one liter of porridge (potage au babeurre). 

The composition of Koumiss varies with its age, containing on 
the first day about .96 per cent of lactic acid and about one per cent 
on the twenty-first day after its preparation. It contains nearly the 
same percentage of alcohol as beer. Koumiss is an agreeable and 
easily digestible preparation. 

Fresh soft cheese contains considerable assimilable casein and 
therefore subserves a useful purpose in proteid nutrition and it has all 
the advantages and none of the disadvantages of milk. Thus the 
soft cheese known as petit suisse contains the following: Albumin 4 
per cent ; casein, 24 per cent; lactose, 2 per cent ; and lactic acid, 
•60 per cent. 

Farinaceous aliments. — Combe* formulates the following 
conclusions: 

1. The carbohydrates, or sugary foods, prevent proteid putre- 
faction in the intestine. • 

2. That in natural digestion, the farinaceous foods (rice, farina 
of cereals and their derivatives) surpass all other carbohydrates 
because they are less easily absorbed and they penetrate more pro- 
foimdly into the intestine and only gradually furnish lactic and 
succinic acids. 

3. That the maximum quantity of farinaceous food must be 
given with each repast and, if possible, to carry out this cramming 
process, this food must be given five or six times a day. 



*L'Auto-Intozication Intestinale, Paris, 1907. There is an English translation of 
this book published by the Rebman Company. 

343 



S p n d y i 



a p 



4. Interdifl as far as possible, all albuminous foodstuffs but -j 
choose among them the least putrescent (like eggs) and when they are ^ 
used, combat their action by an excess of farinaceous food. 

5. In the ordinary forms of autointoxication, millt mixed with ^^ 
farinaceous food is better supported than milk alone. 

6. Avoid fats, which augment putrefaction, and choose butter i" ^_ 
preference. 

If one is desirous of carrying out, if only for test purposes, ai^ 
antiputrid regime, one may select the following: 



Milk, or lactose as a substitute. 

Cooked vegetables, preferably as pur^S. 

Preserved or cooked fruits. 

Weak coffee, tea or cocoa. 

Toast with little butter. 

Farinaceous foods prepared as puddings, or othei 

These must be consumed in abundance. 
Buttermilk or Koumiss. 
Fresh cream cheese. 



I 



Later, if the condition of the patient is ameliorated, easily digestible 
albuminous foodstuffs like eggs, bam and cold meat, together n-ith 
fresh fruits (preferably bananas), may be permitted. 

Antagonistic microbes. — Ever since Metchnikoft directed atten- 
tion to the fact that sour milk microbes are antagonistic to the microbes 
of putrefaction, it is quite the custom in France to employ the former 
in the treatment of autointoxication. The chief characteristic of the 
intestinal dora of the autointoxicated, is the marked diminution of 
the saccharolytic aerobic bacilli and the preponderance of the pro- 
teolytic anaerobic varieties. To modify the foregoing condition a 
vegetarian or lac to- vegetarian or lacto-farinaceous diet is indicated 
on account of the small quantity of proteid matter which it contains 
and the lactic acid which it produces. Another method is to feed the 
subject with lactic acid ferments or microbes which are innocuous 
but exert an inhibitory influence on the microbes of putrefaction. 
There are now several lactic acid culture mediums on the market, 
but many of them seem to lose their therapeutic action wheo prepared 
in the form of tablets or globules. 




splanchnic Neurasthenia 

Unquestionably, the liquid laciobacilline, as it is called, is the most 
eflSident. It may be taken in milk or water directly from the small 
bottles in which it is sold, and one bottle (containing about half a tea- 
spoonful) a day is the average dose. During the first few days, 
digestive disorders may follow its use but soon constipation ceases, 
the stools lose their putrid odor, the breath sweetens and the tongue 
becomes cleaner. The signs of autointoxication disappear slowly 
but surely. To make these good results permanent, the treatment 
is continued on an average for two and a half months. The ferment 
is ordinarily employed in association with the diet, although some 
writers claim that nearly all the effects can be secured from the ferment 
alone. According to Cohendy, it takes about six days before the lacdc 
add microbes change the intestinal flora. If diarrhcea is caused by 
intestinal putrefaction, it is said to be arrested by this bacterio-thera- 
peutic method. 

If lactic add culture mediums cannot be obtained, then buttermilk 
or koumiss may be used. Holt suggests the following formula for 
the domestic manufacture of koumiss: one quart of fresh milk, one- 
half ounce of sugar, two oimces of water and a fresh piece of yeast 
cake (one-half inch square), are put in wired botties and kept at a 
temperature between 60 and 70 degrees F. for one week. The botties 
are shaken Ave or six times a day. They are then put on ice and 
kept ready for use. 

This bacterio-therapeutic method may have to be employed to 
the exdusion of the laco-farinaceous diet for there are some individuals 
who suffer from dyspeptic symptoms if the latter is pursued too 
vigorously. 

Splanchnic neurasthenia. — The chief abdominal 
S3rmptoms of this aflfection are : abdominal sensitiveness, ten- 
derness and enlargement of the liver, and gaseous accumula- 
tions in the bowels. The dominant symptoms of the afifection 
are resident in the nervous system. Depression, or as it is 
popularly called, an attack of "the blues," is scientifically 
speaking, an exacerbation of splanchnic neurasthenia and 
coincident with the depression, there is hepatic enlargement 
and tenderness. Eliciting the liver reflex of contraction will 

345 



S p n d y I t h e r a p y 

at once dissipate partially or completely the liver tenderness 
and enlargement, and will ameliorate the condition of the 
patient. Splanchnic neurasthenics find that their symptoms 
are accentuated after meals and this may be accounted for 
by the augmented amount of blood in the liver at this par- 
ticular time. 

The factors which contribute to the development of 
splanchnic neurasthenia are essentially nerve-force lacking 




Fig. 8q. — Illuacraiing Ihc cartlio-splanchnic phenomenon . The shaded area 
indicates the dullness obtained after vigorous comptession of the abdomen. The 
contiguous area is the superficial area oi cardiac dullness. 

in the muscles of the abdomen and in the nervous mechanism 
which regulates the supply of blood in the abdominal vessels. 
The former factor indicates reduced intraabdominal 
tension, for the greater the latter, the less blood will be 
contained in the abdominal vessels. It is for this reason, 
that one finds in splanchnic neurasthenia the objective signs 
of reduced intraabdominal tension (page 145). There is 
S46 



S p lanchnic Neurasthenia 



■B 



another sign which the author has called the cardio-splAnchnic 
phenomenon*'' (Fig. 89). There is a tendency of the blood 
to accumulate in the splanchnic area, with consequent 
syncope. 

Like the generality of veins, the great splanchnic veins 
are very susceptible to pressure, and the amount of blood 
within them is greatly influenced by the pressure of the 
abdominal walls. Mere pressure of the latter suffices to 
squeeze out of them a large quantity of blood. More 
blood accumulates in the splanchnic veins in the erect than 
in the recimibent posture, and it is not an xmconmion 
observation for syncope to occur in bedridden patients who 
are suddenly constrained to get out of bed. The removal 
of stays in women often induces a feeling of faintness, and 
the same s3nnptom may occur when a large quantity of 
ascitic fluid is removed and, in susceptible subjects, when 
the bladder is emptied or feces discharged. 

HiU has shown that in consequence of some failure, the 
blood gravitates into the splanchnic veins from the right 
heart, and that pressure upon the abdomen will send back 
the blood from these veins to the right heart, and thus re- 
establish the circulation. 

If the lower sternal region, i. e., the part of the sternum 
contiguous to the heart, is first percussed, the sound elicited 
is one of resonance or hyperresonance ; if now, one makes 
vigorous compression of the abdomen, percussion again 
shows that the region in question has become dull or even 
flat. This is the cardio-splanchnic phenomenon and is 
present even in the norm, but when there is intraabdominal 
venous congestion as in splanchnic neurasthenia, this 
phenomenon is much exaggerated and the area of dullness 
is more diflFused. 

By percussing the lower end of the sternum in the erect 

347 



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t h 



a p y 



posture, one obtains a resonance, but when the patient 
assumes the recumbent posture, a duUness supplants the 
resonance. This is the attitudinal cardio-splanchnic phe- 
nomenon. It is present in health but absent when the 
splanchnic vaso-motor mechanism is defective. 

The splanchnic circulation is partly venous and partly 
arterial, and consists of the portal vein and its branches and 
the arterial branches of the celiac axis. When a person 
stands, the splanchnic vaso-motor mechanism causes a 
constriction of the splanchnic vessels and the blood -pressure 
rises, but, if ineffective, it fails to rise or falls. Now, in 
splanchnic neurasthenia, the splanchnic vaso-motor mech- 
anism is exhausted and it is inadequate to prevent a flow 
of blood to the splanchnic vessels. The following test 
demonstrates an adequate automatism of the vaso-motor 
mechanism : 

PULSE-RATE, SYSTOLIC BLOOD-PRESSURK. 

Lying 60 118 

Standing 60 130 

Difference o — 12 mm. 

In the following test, the vaso-motor mechanism is 
insufficient : 

PULSE-RATE. SVSTOLIC BLOOD-PRESSURE. 

Lying 60 104 

Standi n 



Gl'enard^s D 



t s e- a s e 



Respecting the latter method. The dorsal region of the 
spinal cord represents the origin of the majority of vaso- 
constrictors in the body. The splanchnic vaso-motor 
mechanism which controls the vessels of the abdominal 
viscera consists of the splanchnic nerves which are composed 
of fibers issuing from the cord in the 5th to the 12th dorsal 
nerves, inclusive. Reference to Fig. 10, shows that the 
dorsal nerves in question correspond to the spines of the 2nd 
to the 8th dorsal vertebrae inclusive. 

Now, if the spines in question are sinusoidalized, or better 
still, concussed, the cardio-splanchnic phenomenon (page 
346) is at once brought into evidence. In other words, the 
blood is expressed from the abdominal vessels to the right 
heart. 

Concussion then, of the 2nd to the 8th dorsal spines, 
inclusive, is a very active means of augmenting the tone of 
the splanchnic vaso-motor mechanism and constitutes a 
very efficient method of treatment in splanchnic neurasthenia 
and in all forms of intraabdominal congestion even without 
nervous symptoms. 

In Gl^nard^s disease, or enteroptosis, the prolapse of one 
or more abdominal organs is associated with neurasthenic 
symptoms and the wearing of an abdominal supporter 
affords much relief to the wearer. The relief thus attained 
is not due wholly to reposition of the organs, as is instanced 
in the observations of Bial. The latter applied transparent 
bandages to cases of gastroptosis and transilluminated the 
stomachs before and after the application of the bandages. 
No change in the position of the stomach could be noted, 
and it is therefore most likely that abdominal supporters act 
chiefly by compression of the viscera, which, in turn, squeeze 
the blood out of the turgid abdominal veins. 

The author has treated many cases of Glenard's disease 

349 



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a p y 



based on the principle that the symptoms are often dependent 
on a faulty vaso-motor mechanism and by increasing the 
tone of the latter, by sinusoidalization or concussionof the 
spines of the 2nd to the 8th dorsal vertebrce, one may 
ameliorate the symptoms. 



e S i> I e 



n 



CHAPTER X. 

MISCELLANEOUS REFLEXES. 

THE SPLEEN — REFLEXES OF THE SPLEEN — SPLENIC REFLEXES IN 
, TREATMENT — ^UTERUS REFLEX — ^DYSMENORRHEA — THE BLADDER 
REFLEX — THE KIDNEY REFLEXES — ^NERVOUS SYMPTOMS; PAR- 
ALYSIS, CONTRACTURES, ATAXIA. 

THE SPLEEN. 

T^HIS enigmatical organ of the physiologist, like the other 
^ viscera, is not constant in size; on the contrary, the spleen 
contracts and expands synchronously with the periods of 
dig^tion. It attains its maximum dimensions at about the 
fifth hour after a meal and then slowly returns to its previous 
size. According to Schaefer, motor nerve-fibers are con- 
tained in the splanchnic nerves which, when stimulated, 
cause either a contraction or a dilatation of the spleen. No 
doubt the contraction and dilatation of the organ are dependent 
on its intrinsic musculature, that is, the plain muscle tissue 
existing in the capsule and the trabeculae. It has been 
foxmd that when the spleen contracts the liver becomes 
enlarged. It is the popular belief that the spleen is influenced 
by the nervous system and Botkin found that depressing 
emotions increased its size and exhilarating ideas diminished 
it. 

The latter observer also noted that the application of 
the induced current to the skin over the spleen in a case 
of leukemia caused the organ to contract and that each stim- 
ulation was followed by an increase in the number of color- 
less corpuscles in the blood and the condition of the patient 
improved. We will note presently that the spleen may be 
made to contract even in the norm. 

351 



Spondyio therapy 

In fevers there is an acute swelling of the spleen and a 
chronic enlargement of the viscus is observed in malaria 
and leukemia. Enlargement of the organ {splenomegaly) 
is associated with other diseases of the blood, notably 
pernicious anemia, Hodgkin's disease, congenital syphilis 
and Banti's disease. 

REFLEXES OF THE SPLEEN. 

Like the other viscera, two reflexes of the spleen may be 
elicited, viz.y that of contraction and dilatation. 

For diagnostic purposes these reflexes, like other visceral 
reflexes, are obtained by several concussion blows with the 
hammer on a pleximeter while the latter is resting on 
definite vertebral spines. The splenic reflex of contraction 
is elicited by concussing in succession the spines of the first 
three lumbar vertebrae, whereas the splenic reflex of dilatation 
is obtained by concussing the spine of the nth dorsal 
vertebra. The spleen may be brought into evidence by this 
reflex even when percussion shows no area of splenic dullness. 

The contraction and dilatation of the organ are evidenced 
by percussion and to aid the latter, the vibrations of the 
spine and sternum may be suppressed after the manner 
detailed on page 80. 

The results of the concussional manceuvers just cited 
are shown in Fig. 90. 

THE SPLENIC REFLEX IN TREATMENT. 

Only the splenic reflex of contraction has thus far been 
employed by the author for therapeutic purposes, although 
he believes that careful hematologic examinations after 
eliciting both reflexes, may shed some light on the functions 
of the spleen which have thus far baffled physiological investi- 
gations. 

352 




Fig. 90. — Illuslrating the splenic reflexes. The continuous line represents llie 
area of dullness of ihe spleen before vertebral manipulalion. The interrupted line 
within the continuous line represents the splenic reflex of contraction whereas 
the inierrapted line outside of the continuous line represents the splenic reflex of 
dilatation. The lalter reflex measures 9 cm. and the reflex of contraction only 
3 cm. \a Ihe anterior axillary line. 



The fact that the spleen is endowed with contractility 
has engendered the employment of therapeutic measures to 
the splenic region lilte electricity and heat and cold iviih 
the object of reducing the volume of the oi^n. Such 
measures are, however, only illusory, insomuch as any 
irritation of the skin in the region of the spleen produces 
a dilatation of the lungs (lung reflex of dilatation, page 294) 
which, descending over the spleen, gives the erroneous 
impression that the spleen has contracted. 

It was the erroneous observation of Adarao Moscucci 
that led the author to first discover the lung reflex of dilatation. 
Moscucci reported the cure of enlarged spleens in malaria 
by spraying ether over the splenic region. In attempting to 
confirm the observations of Moscucci, the author found 
that the ether acted as a cutaneous irritant and by dilating 
the lungs gave the impression that there was a reduction in 
the volume of the spleen. 

The anatomic structure of the spleen suggests its function, 
viz., a lymph-gland which acts as a receptaculum for foreign 
and noxious elements circulating in the blood. No doubt 
the leukocytes in the spleen assist by their phagocjlic action 
in destroying the noxious elements which have been filtered 
by the organ. Weidenreich has shown that the splenic 
vein contains seventy times as many leukocytes as the 
splenic artery. 

The spleen is a favorite repository for microorganisms and 
it has long been recognized as the habitat of the Plasmodium 
malariae. Indeed, Laveran avers that the plasmodium here 
finds protection from destruction in the circulation. 

The fact has been recognized that cutaneous irritants 
(douches, electricity, etc.) in the splenic region may precipi- 
tate a malarial paroxysm in latent malaria. Here it is 
assumed, that the therapeutic manceuvers in question 



splenic Reflexes 

contract the spleen and thus dislodge mechanically into the 
circulation the plasmodia which have lodged in the organ. 
Quinin has a specific action on smooth muscle and contrac- 
tions of the spleen, uterus and intestines have been observed. 

Now, quinin in its action shows a specific toxicity to the 
organisms of malaria, yet even when the plasmodia cannot 
be demonstrated in the blood of the periphery, a single dose 
of quinin by contracting the spleen may force the plasmodia 
into the circulation and thus make their demonstration 
evident. 

Samuel Hahnemann's homeopathic theory of similia 
similibus curantur was founded on this untoward effect of 
quinin. Hahnemann, at one time, had malaria, and suffered 
from no attack for many years, until one day he tried the 
effect of cinchona upon himself for experimental purposes. 
The ingestion of the drug was followed by a violent rigor 
and a well-marked attack of ague, and thus he argued : If 
cinchona is a remedy for ague, and if in me it has precipi- 
tated an attack of the disease, it must follow that a small 
dose of the drug which produces certain S3niiptoms will cure 
the same S3niiptoms when they are caused by the disease. 

The author has shown that the splenic reflex of con- 
traction may be elicited most effectually by concussion of 
the first three lumbar spines and he has utilized this reflex 
in the diagnosis and treatment of malaria. Thus, in latent 
malaria^ he has precipitated a typic paroxysm (chill, fever 
and sweating) by such concussion. He has also demon- 
strated after the latter manoeuver the presence of plasmodia 
in the blood, although absent previous to the concussion. 

In the treatment of malaria, he employs concussion in 
connection with the use of quinin and, in this way, he has 
achieved excellent results. 

Several cases of pernicious malaria and malarial cachexia 

355 



S p 



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a p y 



are recalled which resisted the action of quinin alone, bm 
when the latter was used in combination with concussion, 
treatment was effective. 

It may also be observed that although in these cases, 
months and even years may elapse before there is any 
reduction in the size of the spleen, concussion of the spines 
of the first three lumbar vertebrae will cause the ague-cake 
to disappear after several weeks treatment. 

Puncture o/Oie spleen has often been done with the object 
of aspirating the juice of the spleen to demonstrate in the 
latter, the plasmodia and typhoid bacilli. The latter are 
almost constantly found in the spleen. Splenic -puncture is 
by no means a harmless procedure and, for this reason, it 
has been abandoned by conservative clinicians. 

Isolation of typhoid bacilli from the blood is a useful 
procedure in the diagnosis of typhoid fever, and the author 
suggests concussion of the lumbar spines to facilitate the 
demonstration of the bacilli In the blood. He has had, 
however, no proof to justify the suggestion. 

The following cases are interesting : 

I. A young man had symptoms suggesting the 
latent or ambululory form of typhoid fever. The spines 
of the first ihrce lumbar vcrlebnE were concussed during 
a sdance lasting Icn minutes. The following day, the 
typic symptoms of typhoid fever appeared and conva- 
lescence was not established until the fiftieth day. 

One could, with reason, regard the development of 
the symptoms following concussion as a mere coinci- 
dence, yet a like observation in two other cases of a 
similar nature would seem to justify the conclusion that, 
in consequence of contraction of the spleen following 
the manceuvcr, typhoid bacilli were forced into the 
general circulation by contraction of the spleen. 

II, A young lady had apyrexia for one month fol- 

356 



Splenic Reflexes 

lowing tjrphoid fever. Her spleen was enlarged and she 
suffered pain (as often occurs from tension of the capsule 
of the spleen) in the region of the organ. An effort was 
made to reduce the volume of the organ by concussion of 
the spines of the first three lumbar vertebrae. After 
three treatments, she suffered a relapse lasting fifteen 
days and roseola, diarrhoea and a step-like temperature 
were prominent symptoms. 

The conditions favoring a relapse in typhoid fever are 
unknown. A relapse is associated very often with some 
indiscretion in diet. 

The author supposes that in these cases reinfection 
results from contraction of the spleen forcing the typhoid 
bacilli into the circulation. Indiscretions in diet are followed 
by an enlargement with subsequent contraction of the spleen. 
For this reason, the author suggests concussion as a thera- 
peutic manoeuver not only to prevent relapses but to hasten 
defervescence in typhoid fever. 

This same therapeutic manoeuver suggests itself in the 
treatment and diagnosis of other infectious diseases associated 
with an enlargement of the spleen. 

It has been known for some time that enlargement of 
the spleen was associated with anemia and cachexia, and 
the condition was specified as splenic anemia or splenomegalia 
cum anemia, but Banti demonstrated that the splenomegaly 
was not secondary as in leukemia, but autochthonous and 
responsible for the S3niiptomatic complex known as BantVs 
disease. 

The author has successfully treated one case of the latter 
disease by elicitation of the splenic reflex of contraction after 
a nimiber of stances of concussion of the spines of the three 
first lumbar vertebrae. 



357 



S p 



t h 



r a p y 



THE UTERUS REFLEX. 

If one electrode from a sinusoidal current is applied 
over the sacrum and an interrupting electrode is fixed over 
the spines of any of the first three lumbar vertebne, a distinct 
contraction of the uterine walls may be observed through a 
speculum. The author has had no experience with this 
reflex in treatment and is therefore unable to determine its 
practical value. 

DYSMENORRHEA. 
Painful menstruation is subdued in conventional practice 
by treatment of the cause and the use of some analgesic 
during the paroxysm of pain. The author has thus far 
examined about fifty patients who suffer from painful men- 
struation and has noted points of tenderness located either 
to the right or left side or both sides of one or more of the 
spines of the first four lumbar vertebrae. Firm pressure 
made with the end of the thumb (page 170) over one or 
more sensitive areas will abolish the pain for several hours 
or during the entire period of the menstruation. The 
latter excellent result, however, is infrequently achieved, 
and it may be necessary to repeat the manoeuver sewral 
times during the menstrual period. The areas of tenderness 
may be marked with a stick of nitrate of silver and some 
member of the family may be taught the method of making 
pressure. In other instances the areas of tenderness may be 
frozen (page 172) and the effect may last during the entire 
menstrual period. Freezing, if effective, is deddedly more 
lasting in its results than pressure. 



THE BLADDER REFLEX. 



The author has investigated this reflex in association 
with Dr. Henry Meyer of San Francisco, an acknowledged 
358 



Kidney Reflexes 

expert with the cystoscope. With one electrode over the 
sacrum and the interrupting electfode at the spine of the 
5th lumbar vertebra, a decided contraction of the wall of 
the bladder and its sphincter can be observed with the 
cystoscope. The sinusoidal current was used and contraction 
of the abdominal wall was excluded. No doubt there is a 
distinct vertebral site for contraction of the sphincter and 
for the detrusor vesicae. However, the reflex in question is 
merely cited as a suggestion to cystoscopists for its elabora- 
tion. The bladder reflex may be utilized in atonic conditions 
of the musculature of the bladder. 

THE KIDNEY REFLEXES. 
PERCUSSION OF THE KIDNEYS. 

Among the cognate branches of medicine, physical 
diagnosis is the least progressive. It still bears the imprint 
of tradition and any attempt to improve upon the methods 
of the founders — ^Auenbrugger, Laennec, Skoda and others — 
is viewed as an act of sacrilege. It is suggested in the text- 
books, that owing to the anatomic position of the kidneys 
(Fig. 11), their boundaries cannot be limited by percussion 
and that the thick layers of muscles behind yield a dullness 
which an organ as thin as the kidney could not increase. 
It may be afiirmed, however, that, as a rule (excluding 
non -resonant impacted feces in the colon), one may deter- 
mine the lower and a portion of the outer border of each 
kidney by contrasting its dullness with the tympanicity of 
the ascending and descending colon which lie anterior to 
each organ. If it is a question of tympanicity which obscures 
the dullness of the kidney, this objectionable feature may 
be obviated by suppressing the vibrations of the spine by 
having an assistant fix his hand on the latter during per- 
'cussion {yide vibro-suppression). If it is a question of 

359 



S p 



t h 



p 1 



dullness of the spinal muscles, have the patient lean far 
backward to relax the muscles during percussion. Having 
defined the kidneys by percussion, concuss in succesaon 
with the hammer and pleximeter (Fig. 2), the 6lh, 7th and 
8th dorsal spines ; percussion executed at once now demon- 




Fig. 9:. — Kidney reflexes of 
e reprcscnls the area of k id ncy-du Lines 
n and dilatation 



and dilatation. ". 
ind ihe dotted lines within and without 

ipeclively. 



strates an increase in the area of renal dullness which is the 
kidney reflex of dilatation. Concussion of the 12th dorsal 
vertebral spine causes a decrease in the area of renal dull- 
ness, which is the kidney reflex of contraction (Fig. 91 ). 
The latter, like other visceral reflexes, are of limited duration. 
It is known that by means of the oncometer, that the kidney. 
like the spleen, shows variations in volume. The r eal 
volume of the living kidney depends upon the distension: 
360 



Kidney Reflex 



WBBk 



its structural elements, upon the quantity of lymph and 
specially upon the amoimt of blood in its blood-vessels. 
When the latter dilate the kidney increases in size and 
when the vessels contract, the kindey diminishes in volume. 

THE KIDNEY REFLEXES IN DIAGNOSIS AND TREATMENT. 

Insomuch 2^ the kidney reflexes have only recently been 
discovered by the author, anything he may say concerning 
their value in diagnosis and treatment can only be theoretic. 
One could assume that backache due to distension of the 
capsule of the kidney could be relieved by diminishing the 
volume of the organ by concussing the 12th dorsal spine 
with the hammer. Pain due to the presence of a renal 
calculus would be intensified by the same manoeuver. 

A dull area supposed to be the kidney would increase with 
elicitation of the kidney reflex of dilatation and would 
decrease by elicitation of the counter kidney reflex. Surgery 
has been invoked in the treatment of chronic nephritis. 

Thus, some surgeons have resorted to puncture (reni- 
puncture) of the kidney and others to incision of the capsule, 
thus assuming that the fundamental condition demanding 
relief was tension of the organ. Others assume that nephro- 
pexy relieves the condition by establishing vascular adhesions 
which carry an additional supply of blood. 

The author has treated only one case of parenchymatous 
nephritis by concussion, but the results are nevertheless 
interesting. Acting upon the theory that a better blood - 
supply was essential, the treatment consisted of daily stances 
of concussion to elicit the kidney reflex of dilatation. After 
about seven treatments, the albumin increased in the urine, 
the blood-pressure became higher and edema of the ex- 
tremities developed. Concussion of the spine of the 12th 
dorsal vertebra was then executed to elicit the reflex of 

361 



Spondyloth 



a P S 



contraction and thus diminish the volume of the kicinev. 
After a few treatments the edema rapidly disappeared, the 
blood -pressure sank to 165 mm. (from 210 mm.) but the 
albumin continued in the urine (at this time of writing), 
although slightly diminished in percentage. 

In interstitial nephritis, Increasing the volume of the 
kidney (by eliciting the kidney reflex of dilatation) would 
theoretically be indicated. 

NERVOUS SYMPTOMS. 
PARALYSIS. 

Reference has already been made on page 11 to the 
spinal muscular reflexes. 

In electrotherapeutics, the average neurologist concerns 
himself with the employment of only the Galvanic and 
Faradic currents. He has little faith in influencing the site 
of the lesion and contents himself with stimulation of the 
paralyzed muscles, hoping that such irritation may act in- 
directly at the site of the lesion. 

Reference has already been made to the action of the 
sinusoidal current on page 11, in provoking contraction of 
the muscles by central stimulation. Other currents are not 
effective in achieving this object. By vertebral stimulation, 
one may provoke contractions of muscles which are not 
possible by the conventional method of peripheral applica- 
tion. The contractions of the muscles are bilateral, and the 
latter fact is of great importance in comparing the contrac- 
tions on both sides of the body. The illustration on page 13 
will aid the physician in contracting definite groups of 
muscles. Thus, as an example, one may cite the following: 
.\ssuming that the patient cannot extend the leg upon the 
thigh. Here the quadriceps femoris is implicated. Reference 
to Fig. 14 shows that the cell-bodies of origin of thi 
riceps femoris are located in the 2nd and 3rd lumbar s 
362 



Contractures and Ataxia 



Boa 



ments of the cord and that these segments correspond to 
the loth dorsal spinous process (page 14 and Fig. 10). To 
stimulate the muscle in question the exciting pole, i. e.^ the 
interrupting electrode of the sinusoidal current is fixed at 
the spuious process of the loth dorsal vertebra, whereas 
the indifferent electrode is placed over the sacrum. 

CONTRACTURES. 

When definite groups of muscles are weakened or para- 
lyzed, the antagonistic muscles not encountering the normal 
resistance to their action, move the limb in an abnormal 
position and hold it there. The latter is a passive contracture. 
K a limb is fixed in an abnormal position by a tonic con- 
traction of certain groups of muscles, one is dealing with an 
active or spastic contracture. Concerning the reciprxx:al 
action of antagonistic muscles, the researches of Sherrington 
show in brief that the inhibition of the tonus of a voluntary 
muscle may be brought about by the excitation of its an- 
tagonist. To overcome contractures, vertebral sinusoidali- 
zation is very effective in stimulating groups of muscles 
antagonistic to the shortened muscles after the method of 
segmental localization just described under paralysis.* 

ATAXIA. 

The attention of the reader is directed to the remarks 
on page 28, concerning the knee-jerk in locomotor ataxia. 
It is generally conceded that in the latter affection the ataxia 
is caused either by a loss or disturbance of the afferent 
impulses from the deep tissues, joints and muscles. In 
addition there is a disturbance of the muscular sense and 
hypotonia (q. v.) is present. 

Attention has already been directed on page 165 to the' 
re-education of co-ordinated movements in locomotor ataxia 

*For further reference to this method of treatment, vide footnote on page 147. 

363 



Spondylo therapy 

which has yielded excellent results. The re-education 
method is based on the observation that if an ataxic indi- 
vidual repeats a movement several times in succession, the 
ataxia in such a movement becomes less evident. The 
tabetic patient has an erroneous idea of the movement which 
he is executing, with the consequence that the movement 
is faulty. The "movement-memories" which he had in 
health no longer subserve his purpose and a new series of 
"movement-memories" must be acquired corresponding to 
the impressions which are received through neurons which 
are still intact. 

The author has shown that whereas the aflFerent paths 
are compromised, the descending or motor paths may not 
be impaired. Taking advantage of the latter fact he effects 
re-education of the defective movements by vertebral 
sinusoidalization with results which prompt him to say 
supersede the conventional exercises in rapidity of action. 
The method, in brief, is to bring into action definite muscle- 
groups of the lower extremities by applying one large 
electrode to the region of the sacrum and the interrupting 
electrode over definite spinous processes (page 13). The 
author cautions against the emplojment of a strong sinu- 
soidal current. The latter should only be suflBciently strong 
to provoke slight contractions of the muscles; otherwise, a 
hj'pertonicit)' of certain muscles ensues, resulting in muscle- 
bound extremities making locomotion e\'en more difficult 
than before the use of the current in question. Not infre- 
quendy, the large electrode may be fixed in the lower dorsal 
region, and the interrupting electrode over definite spinous 
processes. One of my ataxic patients had difficulty in loco- 
motion owing to abduction of the lower extremity. By bring- 
ing the adductors into play by x-ertebral sinusoidalization the 
difficulti' was corrected. The relief of p.\ix in locomotor ataxia 
mav be attained by the methods suggested in chapter XI. 



Therapeutics of Pain 



mm 
99 



CHAPTER XL 

THE THERAPEUTICS AND DIAGNOSIS OF PAIN. 

SEGMENTAL-ANALGESIA — CONCUSSION-ANALGESIA — SEGMENTAL-LO- 
CALIZATION — THE TRIGEMINUS NERVE — SINUSOIDAL-ANALGESIA — 
SEGMENTAL-PSYCHROTHERAPY — SEGMENTAL-ANALGESIA OF THE 
VISCERA — SEGMENTAL-ANALGESIA IN DIAGNOSIS — ^PHYSIOLOGY OF 
SPONDYLOTHERAPEUTIC METHODS. — SPINAL NERVE-TRUNK ANAL- 
GESIA—CORTICAL SINUSOIDALIZATION. 

'T^HE pharmacotherapy of pain concerns itself with the 
-*" use of drugs known as anodynes or analgesics which 
annihilate sensation either through the brain (opium and 
its derivatives) or by enfeebling the heart, which relieves 
the hyperemic pressure on the nerve-tissues. 

Local anesthesia is effected by cocain and its substi- 
tutes. Aconite primarily causes local irritation followed by 
anesthesia, but it produces no inflammation of the part. 

Among the aromatic series, carbolic acid is the most 
important local anesthetic. By applying a drop of the acid 
to the skin, one is able to puncture the latter without pain. 
Among the mechanic methods are : protracted tepid baths, 
freezing, cupping and counterirritation. 

In the treatment of pain by methods other than drug- 
giving, it is customary to employ agents at the peripheral 
site of the pain, thus ignoring the ''law of eccentric projection,^^ 
viz., in stimulation of a nerve, irrespective upon which point 
of the course of the nerve it acts, the perception of a pain 
is transferred to the periphery. Pain perception results 
from an accumulation of individual stimulations in the gray 
substance of the spinal cord. Thus, in the employment of 
ouJT peripheric methods, we usually disregard the true origin 

365 



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t h 



a p y 



of the pain. That the average physician ignores the central 
origin of pain may be exemplified by the following case: 

A middle-aged individual suffered for four yeare 
from a brachial neuritis. The pains were so violent 
that morphin was habitually used; in fact, his last 
physician instructed him how to use the hypodermic 
syringe. Ever since his trouble commenced he has trav- 
eled from city to city seeking relief. Every conceivable 
method known in physiotherapy was employed, but 
always at the peripheral site of the pain. An examination 
revealed a few points of vertebral tenderness at the exits 
of some of the spinal nen'es, whereas others were de- 
veloped as a result of manipulation of the peripheral 
areas of tenderness, The paravertebral area of vertebral . 
tenderness was frozen most thoroughly and for the first 
^^^^ time in four years the patient had a surcease of 

^^^^H his pain for about eight hours. A second freezing gave 

^^^^^^ relief for two days, and a few further freezings sufficed 

^^^^E for a cure.* 

^^^H SEGMENTAL -ANALGESIA. 

^^^F Under this caption the author refers to the annihilation 

^^V of pain in slcin-areas and viscera related to different spjnal- 

^^1 segments. Cutaneous and visceral analgesia may be achieved 

^^V by the following methods : 

^^1 CU1 

l 



I 
I 



I. Concussion. 

3. Slow sinusoidal current. 

3. Freezing. 

4. Pressure {vide page 170). 

Other remedial measures (such as the high frequency 
current, rapid sinusoidal current, Galvanic and Faradic 



Dl equally amenable to such rapid results, and 
freeze the sensitive peripheral nerves as a palli- 
e, insomuch as they may ttpresenl the lilc of a 
3 is usually the case, at the points of exit of (be 

366 



may be necessary t 



oncussion - Analgesia 

electricity, phototherapy, cupping and counterirritation ) 
have been tried with the same object in view but without 
results. 

CONCUSSION-ANALGESIA. 

The fear of employing forcible concussion of the spinous 
processes and the use of ineffectual apparatus have deterred 
physicians from obtaining more definite and decided results 
from vibro-massage. Reference to the foregoing facts has 
already been made on page 1 78. Here, as elsewhere in this 
work, the results cited have been achieved by the pneumatic 
hanmier, but any other apparatus yielding a series of strong 
percussion blows, will no doubt yield like results. 

Preliminarily, the following facts are worthy of emphasis : 

1. Concussion and sinusoidalization stimulate the motor 
component of a spinal-segment and subdue its sensory 
constituent. 

2. The sensory component of a normal spinal-segment 
is less amenable to concussion, sinusoidalization and freezing 
than a hyperesthetic segment. 

In other words, concussion, sinusoidalization and freezing 
show a more decided analgesic action on hyperesthetic 
viscera and peripheral areas than when the tissues in question 
are normal. In the employment of the foregoing methods, 
the analgesia is bilateral. 

SEGMENTAL -LOCALIZATION. 

Reference has already been made to this subject on page 
30. Assuming that the patient has pain in one of the skin- 
areas (Fig. 15), it is not difficult to ascertain the relation 
which a given area bears to a spinous process by con- 
sulting Fig. 10. 

Thus, a patient suffers from pain on the anterior surface 
of the toes (Fig. 15) involving the second sacral segment. 

367 



S p 


n d y I t 


/; e 


'• " ;> J' 1 


[ 


^ 


r 


fj 


^J, 




%iA 






Li^tf^--"'- '* 


-.-■'^^^ 


^"^-fc, '" 


0^ 


^^m „ / 


5^^ 


yML 


j„..ajS 


SM'"- V 


.\ 's^ 


l^^l '''' 


mi 




i\ "* 


HK 1 


'■"-fljB 


1 iT'A li ' 


)\ffs 


^^Hit "'■ 


'f'.JK^ 


M " I'm its-yf J 


m 1 "' 


7>J»\ '" 


Um 


^ '??\ wi Ih 


v^ 


'^^^X-sa 


JtWi 


■ ) 1 W\''^'' /Y/ 


j aw 


'^B vL 


w W 


l|"'l ^ ^yf 


1 JM 


L^"*w 


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a / 


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k/''" 


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1 


H 


K 


1 


HI 1 


n 


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«"-• 


■j / 


w fl 


; 


i \ 


)|j 


I—" 


■"'-i 


Pls^ 


(^ 


(P 


Fig. gi 




the diSere 


t spinal-seitnienis. 
related toHU icg- 


The numbe 


rs refer to the various !pinous procasts 


which arc 


meats and 




or frozen. 


cause analgesk in 


the diUccent skin-aieas. C, ceivical; D, dorsal; 


S, sacral. 


Thus CDS «K- 


nifics thai 


•oncussion, sinusoidallMtion or freeiing 




' to Ihe lifth dorsal spine will render [he skin-area analgesii: relate 


d to the 8th dorsal 


segment 








KiG. 9J 


— Showinn skin-areas on the posterior surface of the 




f to ihe diflereni spinal-segmeQls. The numbers lefe 


to the var 


lous i^fumt I^^H 


MJ« related 


to Ihe segments of tbe cord. 

368 




J 



Segmental - Localisation 

Reference to Fig. lo, shows that the segment in question is 
related to the 12th dorsal spine. The author has simplified 
segmental-localization in Figs. 92 and 93. 

Assuming that a patient, has a neuritis in the region of 
the arm corresponding to the 5th cervical segment (Cs, Fig. 
92). If one now concusses the 3rd cervical spine (which is 
related to this segment), the spontaneous pain disappears 
and analgesia may be noted objectively in C5. 

Concussion is without doubt superior to slow sinusoidal- 
ization and freezing in efiPecting this object. 

In most instances, this analgesic effect is noted after 
concussion for about three minutes, although a longer time 
may be necessary to effect this object. The duration of the 
analgesia, %. e., insensitiveness to the prick of a pin, is usually 
of shorter duration than the relief from pain experienced by 
the patient. Although the pain-sense is abolished, the sense 
of touch may be intact. 

Another example may be cited illustrating the importance 
of segmental-analgesia. A patient has lumbago and the 
sensitiveness of his skin does not permit of the local applica- 
tion of a suflSciently strong sinusoidal current. Note that the 
skin of the lumbar region corresponds approximately to the 
9th, loth and nth dorsal segments, which in turn are related 
to the 5th, 6th and 7th dorsal spines. If the latter spines 
are now concussed for several minutes, the analgesia of the 
lumbar region permits of the electric application equal to at 
least three times its original strength. 

SEGMENTAL-LOCALIZATION BY THE ELiaTATION OF VERTE- 
BRAL TENDERNESS. 

This subject has already been discussed on page 71. In 
brief, when a sensitive peripheral structure is subjected to 
pressure (e. g., a sensitive nerve), or manipulated {e. ^., a 

369 



S p n d 



I 



a p y 



sensitive joint), within a minute an area of vertebral tender- 
ness (corresponding to the roots of the spinal nen'es) mav 
be elicited by deeppressure at the exits of the ner\'e or nerves. 
This area of paravertebral tenderness is usually of short 
duration. 

To locate the segment of the cord related to this area, 
the spinal nerve may be traced to its segment (Fig. lo), or 
the table on page 37 will show its relation to the spinous 
processes. 

The fact of the matter is that the author's method of 
concussion -analgesia shows that the skin-areas ordinarily 
accepted as related to definite spinal -segments are only 
partially correct. It is, for the latter reason, as will k 
discussed later (under freezing), that segmental -localization 
by the elicitation of vertebral tenderness is often preferred. 



A patient has an mdammation of tfae shoulder- joint 
(omarthritis) with adhesions. It is necessary in conse- 
quence of the latter to give reUef to the ankylosis and 
pains, but owing to the pain consequent upon manipula- 
tion of the joint, it is impossible to execute sufficient 
force. There are no areas of vertebral tenderness until 
after manipidation of the joint for several seconds, when 
tender points may be delected corresponding to the and, 
3rd and 4th dorsal spines. The spinal nerves which 
make their exit at these points correspond approximately 
to the 2nd, 3rd and 4th dorsal segments. Therefore, 
after concussion of the 6th and 7th cervical spines and 
ist dorsal spine for about three minutes, the shoulder- 
joint may be manipulated with ajmost as litde pain as 
though the patient were under the influence of an 
anesthetic, 



I 
I 



From a therapeutic standpoint, it may be argued that 
the relief of pain secured by concussion is merely palliative 
and is productive of no better results than from the employ- 
370 



rigeminus Nerve 

ment of the conventional analgesics. In a sense, this con- 
tention is correct for the author has had recourse to con- 
cussion daily or even twice daily, for weeks in many cases of 
neuritis and other painful affections, securing thereby only 
relief from pain. 

However, in some chronic painful affections, concussion 
was almost marvelous after several applications in giving 
permanent relief. 

Here one is constrained to conclude that the lesion is 
not peripheral, but central, and that direct spinal -concussion 
effects some intra-spinal change (virf€ physiology of spon- 
dylotherapeutic methods). 

SEGMENTAL LOCALIZATION OF THE PERIPHERAL NERVES. 

Lesions of the peripheral nerves yield symptoms quite 
distinct from those of the spinal cord itself. The sensory 
symptoms consist essentially of numbness and tingling in 
the areas related to the peripheral nerves and the perception 
of pain, touch and temperature are usually only slightly 
impaired. The affected nerve is very sensitive to pressure 
and points douloureux (page 185) may be detected along the 
course of the nerve. The peripheral distribution of sensory 
nerves (after Bailey) is shown in Figs. 94 and 95, and by 
consulting Fig. 10, their relation to the spinal-segments 
may be determined. The latter fact is of importance when 
it is desirous of annihilating (by concussion -analgesia) pains 
of the nerves in question. 

THE TRIGEMINUS NERVE. 

Reference to Fig. 1 5 shows that only a small part of the 
skin of the head and face is supplied by the cervical spinal 
nerves. The sensory division of the trigeminus supplies 

371 



S p n d y I t h e r a p y 




Fic. 94. — Peripheral distribution of sensory nerves. 

372 



Sensory Nerves 




Flo. 95-— Peripheral distribution of a 
373 



the skin of the face, the mucosa of the mouth and nasal 
cavities and the cornea. 

The author has endeavored to influence the sensory 
functions of the trigeminus by concussion, sinusoidalization 
and freezing over the site corresponding to the location of 
the Gasserian ganglion (Fig. 96), from the sensory cells of 
which the sensory root of the trigeminus arises. The results 
have not been as good as when the spinal nerves are similarly 
influenced. Here freezing (at the site of the Gasseriaji gan- 




wtlh its three chief t 



glion) and sinusoidalization are more effective than coj 

cussion.* 

SINUSOIDAL-ANALGESIA. 

The sinusoidal current is less effective than concussion 
in producing segmental -an algesia. Only the slow sinusoidal 
current is effective for this purpose and it is obtained from 
the Victor multiplex sinusoidal outfit. The current bombards 
the segment with a series of. painless concussion -blows. A 

*The author has nat had a sufficient number of cases of Dcuralgia of ihe trigeminus 
nerve lo test the value of freezing and the stmv sinusoidal niirent (one electrode 
lo the back of the neck and a smaller cleclrode over the Gasserian ganglion). 
The suggestion having been given, however, dentists may elaborate o "" 
method and test its cfficienry. 



374 



d 



S e g m e n t a l-Freexing 

strong current must be used and the duration of the stance 
must not be less than five minutes. Small electrodes are 
placed on either side of the spinous process (corresponding 
to the segment), or, if more spinous processes represent the 
segment^ area of pain, the electrodes are placed along the 
line of the spine so as to cover the entire segmental area. 

SEGMENTAL-PSYCHROTHERAPY. 

Reference has already been made on page 172 to the 
subject of psychrotherapy. Freezing acts more rapidly 
than the slow sinusoidal current and concussion in producing 
segmental analgesia. It is used exclusively by the author in 
influencing visceral sensation. The effects, however, in 
comparison with the other methods are not as permanent, 
and one is handicapped in its repetition by the soreness of 
the skin which it produces. It may be repeated, however, 
several days in succession when ether is employed for 
congelation. 

To inhibit peripheral and visceral pain either the spinous 
process over the segmental area is frozen or what is equally 
efficient, freezing is executed over the areas of vertebral 
tenderness corresponding to the point of exit of the spinal 
nerves from a given segment. 

A patient has a painful shoulder-joint in association 
with a neuritis. Manipulation of the joint develops 
areas of vertebral tenderness (previously absent) at the 
points of exit of the 2nd, 3rd and 4th spinal nerves. 
These areas are marked with a pencil. Pressure over 
the sensitive nerve develops an area of vertebral tender- 
ness at the 7th cervical nerve corresponding to a point 
between the spines of the 6th and 7th cervical spines. 
The latter area is also marked with a pencil. Thorough 
freezing over the 2nd, 3rd and 4th spinal nerves inhibits 
the pains in the shoulder-joint and freezing over the 2nd, 

375 



3rd and 4th spinal nen-es arrests the pains of the neuritis. 
The treatment to be efiective must be reiwated daily. 
In some instances it is advisable to freeze not only the 
points of exit of the spinal nerves, but likewise the seg- 
ments corresponding to these nerves. In intractable 
cases, the author has recourse to re-enforced freezing 
(page 173) or he connects a large hyjKxiermic needle 
with his atomizer by means of rubber tubing and freezes 
(with ether] the subcutaneous tissues by aid of the needle. 



SEGMENTAL-ANALGESIA OF THE VISCERA. 

The reader is referred to page 58, where consideration 
was given to the dermatomes of Head. It may be observed 
that the latter noted that the distribution of the lesions in 
patients with herpes zoster corresponded with the areas 
of cutaneous pain and tenderness occurring in certain 
visceral affections and by comparing the areas implicated 
in cases of herpes zoster with disturbances of sensation in a 
number of cases of nervous diseases (with lesions of the 
spinal cord), he was able to map out the dermatomes. The 
latter correspond to the segments of the cord and not to the 
peripheral distribution of the posterior roots. 

In the following table tlie author has located the segments 
of the cord related to the viscera after the following manner ; 
repeated manipulation of a ^nsitive viscus will develop an 
area of vertebral tenderness corresponding to the roots of 
the spinal nerves. Having located the sensitive nen'es, it 
was not difficult to trace their relation to definite spinal- 
segments. 

376 



S e g m e n t a I -Analgesia 



SPINAL-SEGMENTS ASSOCIATED WITH ViSCERAL SENSATION.* 






RELATION TO 


ORGAN. 


SEGMENT OF CORD. 


SPINOUS PROCESS. 

1 


Heart. 


Ill C and I, II, III D. 


! 2nd, 6th and 7th C. 


Lungs. 


IV C and I, II, III, IV, 


' 2nd, 6th, 7th C and ist, 




V, VI, VII, VIII, IX 


2nd, 3rd, 4th and 5th 




D. 


D. 


Breast. 


IV and V D. 


ist and 2nd D. 


Esophagus. 


V, VI, VIII D. 


2nd, 3rd, 4th and 5th D. 


Stomach. 


Ill and IV C and VI, 


ist and 2nd C and 3rd, 




VII, VIII, IX D. 


4th and 5th D. 


Stomach (Cardiac 


VI and VII D. 


3rd and 4th D. 


end). 






Stomach {Pyloric 


IX D, 


5th D. 


end). 






Intestines. 


IX, X, XI and XII D. 


5th, 6th, 7th, 8th D. 


Appendix. 


X and XI D. 


7th D. 


Rectum. 


II, III, IV S. 


1 2th D. 


Spleen. 


XI D. 


7th D. 


laver and Gall- 


VII, VIII, IX, X D. 


4th, 5th and 6th D. 


bladder. 






Kidney. 


X, XI, XII D. 


6th, 7th, 8th D. 


Ureter. 


XII D and I L. 


8th, 9th D. 


Bladder. 


XI, XII D, I Land I, II, 
III S. 


7th, 8th, 9th, 1 2th D. 


Prostate. 


X, XI, XII D, III L and 


6th, 7th, 8th, loth, 1 2th 




I, II, III S. 


D. 


Epididymis. 


XI, XII D and I L. 


7th, 8th, 9th D. 


Testicle and Ovary. 


X D. 


6th D. 


Uterus and 


X, XI, XII D, I Land I, 


6th, 7th, 8th, 9th, 1 2th 


appendages. 


II, III, V S. 


D. 



SEGMENTAL -ANALGESIA IN DIAGNOSIS. 

"The Paris Neurological Society'' concluded that all the 
symptoms legitimately included under hysteria are imposed 
by suggestion, and this conclusion refers with all cogency 
to the traumatic neuroses. The latter, it is argued (spinal 
commotion), cannot give rise to symptoms of the character 



*C, cervical; D, dorsal; L, lumbar; S, sacral. 

377 



Spondyloth 



r a p y 



and duration complained of by tiie victims of " railway 
spine." The foregoing contention cannot be correct inso- 
much as the author has endeavored to show that concus- 
sion of definite spinal- segments in even normal subjects 
will produce analgesia and anesthesia in definite regions 
of the body. 

Suggested, auto-suggested and kysleric pains are amenable 
to diagnosis by segmental -analgesia. 

Let one assume that the patient has a jomt-pain. If the 
skin over the segment corresponding to the joint in question 
is frozen, or the spine is concussed, temporary evanescence 
of the pain should ensue. The foregoing observation is 
equally applicable in the hyperalgesia of neurasthenic 
patients. 

Neukaigic pains may be peripheral, i. e., they are local- 
ized in areas corresponding exactly to the peripheral dis- 
tribution of the nerve-trunk or nerve involved (Fig. 94). 

Here, thorough freezing over the entire area of sensitive- 
ness will inhibit the pains. The pains may be due to irritation 
of the sensory roots. Here, freezing at the vertebral exit of 
the affected nerves will assuage the pains. 

The pains may be intraverlebral in origin (spinal -tumors, 
tabes, myelitis, syringomyelia, etc.) Here, freezing of the 
spinal segments is alone effective in inhibiting the pains. 

In pains of visceral origin, the author employs freezing 
to the exclusion of other expedients in diagnosis. 

Let us assume that the differential diagnosis rests between 
an appendicitis and a liver or gall-bladder disease. Referring 
to the table on page 377, it will be noted that the loth and 
nth dorsal segments are related to the appendix. If now. 
one freezes thoroughly the region corresponding to this 
segment (7th dorsal spine), the pains, if caused by app 
dicitia, will be inhibited. 

378 



Physiology of Methods 

Again, after such freezing, the previously sensitive 
appendix may be palpated without pain. 

Thus it is, one may exclude definite viscera as implicated 
in disease. 

Assuming one has palpated a sensitive organ supposed 
to be the kidney. 

In the table already referred to, the 6th, 7th and 8th 
dorsal spines are related to the segments associated with 
the kidney. If the spines in question are concussed or 
the skin over them is frozen, manipulation of the organ (if 
it is the kidney) should be painless. 

The dermatomes of Head should no longer be in evidence 
if definite spinal -segments related to the different viscera 
are frozen or concussed. 

Associated painful areas related to visceral disease (Fig. 
27) should disappear when the segments corresponding to 
the viscera are concussed, sinusoidalized or frozen. 

In visceral disease, the irritation develops an area of 
vertebral tenderness which is accentuated by palpation of a 
sensitive organ (page 369). Here, freezing of the area 
of tenderness will not only inhibit the pain, but will permit 
of painless palpation of the organ. The vertebral tenderness 
from cutaneous or visceral irritation is usually temporary 
in duration, and when the tenderness persists, it is probably 
due to changes in the roots of the spinal nerves (ascending 
neuritis). It is in this way only that one is able to account 
for the pains which outlast the cure of a visceral disease 
(excluding, of course, conditions in juxtaposition to the 
organ). The author has never been able to influence the 
sensibility of the rectum. 

PHYSIOLOGY OF SPONDYLOTHERAPEUTIC METHODS. 

Physiologists are not in accord whether the spinal cord, 

379 



S p n d y I 



h 



like the peripheral nerves, reacts directly to electric and 
mechanic stimuli. Those who oppose the excitabilitj- of 
the cord claim that any reaction is dependent on stimulation 
of the roots of the spinal nerves which give rise to move- 
ments or sensation. 

The clinician, however, has evidence to show that the 
spinal cord Is excitable to direct stimulation. 

Experiments show that most motor nerve-cells dischai^ 
their motor impulses at a rate of about ten per second, and 
if these cells are stimulated artificially, the motor discharge 
is about the same rate as the normal. 

This reaction of the nerve-celis of the cerebrum and cord 
is endowed with a definite rhythm which has been com- 
pared with the rhythmical beat of the heart. 

After the discharge of an impulse the cells fall in' 
refractory phase for a period of time lasting about 
second. When a nerve-cell has discharged a strong impute 
as a consequence of summation of its stimuli, it is exhausted, 
and requires a certain time to be recharged. 

Concussion is a mechanic stimulus and is equivalent to 
a blow, pressure, pinching or section. Mechanic stimuli are 
only effective when they are applied with sufficient rapidity 
to produce a change in the form of the nerve -particles. 
When a motor nerve is stimulated, the resultant is motion 
and pain if a sensory ner\'e is stimulated. 

If the continuity of the nerve is interrupted or the moi 
ular arrangement is disturbed by a mechanic stimuli 
conduction of an impulse is interrupted and the excitability 
of a nerve is either diminished or extinguished. In con- 
clusion one may say that concussion of short duration 
augments the excitability of the ner\'es, but when prolonged, 
the excitability is diminished or abolished. 

Pressure if continued upon a mixed nerv-e, paral; 
^80 



Physiology of Methods 



■B 



the motor earlier than the sensory fibers. If the pressure 
is applied gradually, the nerve may be rendered inexcitable 
without demonstrating any evidence of its being stimulated. 
Pressure on a mixed nerve extinguishes reflex conduction 
sooner than motor conduction. 

SiNUSOiDALizATiON is the equivalent of an electric 
stimulus. An electric current shows its most powerful 
action upon the nerves at the moment it is applied, and at 
the moment when it ceases, and any increase or decrease 
in the strength of a current acts as a stimulus. When the 
current is flowing through a nervous structure, a condition 
known as electrotonus occurs, whereby the physiologic 
properties of the structure are greatly modified. 

The rapid sinusoidal current is stimulating, whereas the 
slow sinusoidal current jrields a series of electric shocks. 
In the application of the latter current to the spine no motor 
efiFects are observed, the action being limited to subduing 
the sensory component of a spinal-segment. 

Freezing. — ^The author has endeavored, by a series of 
histologic examinations, to explain the rationale of freezing 
as a remedial agent, but the microscope affords no clue. 
It certainly does not act by counterirritation, insomuch as 
the latter shows none of the immediate analgesic effects of 
congelation. The local application of cold probably acts 
as a shock, thereby diminishing the conductivity of the 
nerves and annulling the functions of the centers in the 
cord. The initial contraction of the vessels and tissues is 
followed by a greater dilatation and turgescence. The sensory 
nerves are paralyzed with loss of sensibility. In fact, when 
the temperature is sufficiently low, the excitability of all 
the nerves is diminished. 



381 



SPINAL NERVE-TRUNK ANALGESIA. 

It is known that if cocain is injected into the tissues about 
a nerve-trunk, anesthesia follows in the area supplied by the 
nerve. Anesthesia ensues inabout five minutesand lasts aboil 
fifteen minutes. It is evident that if the injection is eifective, 
there is an absolute block to the transmission of afferent and 
efferent impulses. The foregoing fact is of great importance 
in spondylodiagnosis and spondylotherapy. 

For local anesthesia, cocain is usually employed, but 
owing to the occasional toxic symptoms arising from its 
use, it has been substituted by eucain hydrochlorate, stmma 
and other local anesthetics. 

The danger from cocain is minimized if the following 
precautions arc taken: i, Never inject more than one-third 
of a grain hypodermatically ; 2, Never inject the drug into a 
vein; 3, Never use it if the kidneys are inefficient; 4, The 
patient should be in the recumbent posture; 5. Use the infil- 
tration-anesthesia of Schlcich. Schleich's formula may now 
be obtained in tablets and one tablet is dissolved in 100 
minims of sterilized water. This formula is absolutely 
innocuous: the formula No. 3 containing only i-ioo grain 
of cocain. 

The infiltration can be made painless by touching the 
point where the needle is inserted with pure carbolic acid 
or by freezing the spot. It is well to remember that if one- 
quarter of a pound of ice (broken into fine bits) is mi.xed 
with one-eighth of a pound of salt and placed in a gauze- 
bag, the application of the latter to a part causes analgesia 
in about fifteen minutes. 

A hot solution of the Schleich formula is more efficient 
than a cold solution, 

A moderately long needle attached to the barrel of the 
382 



Cortical Sinusoidalixation 

syringe is used and made to penetrate the tissues of the back 
approximating the exit of the spinal nerves as shown in 
Fig. ID. Assuming that one wishes to make the uhiar nerve 
analgesic. Reference to Fig. lo shows that the nerve from 
which it arises makes its exit between the 7th and ist dorsal 
vertebrae and between the ist and 2nd dorsal vertebrae, 
hence the infiltration-anesthesia must include the para- 
vertebral area in question. 

One may also recall the fact, if cocain, or its substitutes, 
are interdicted, that infiltration of the tissues with warm or 
cold sterile water is often very efficient in causing anesthesia. 

CORTICAL SINUSOIDALIZATION.* 

In 1870, Herbert Spencer declared that different parts 
of the cerebrum must subserve different kinds of mental 
action. 

Hughlings Jackson affirmed that the gray matter of the 
convolutions was really excitable, but physiologists regarded 
his observations as ingenious speculations insomuch as there 
was no evidence that the cerebral cortex responded to any 
of the ordinary stimuli of nerves. 

In 1870, Fritsch and Hitzig, established a new era in 
cerebral physiology, viz., that the application of the galvanic 
current to the surface of the cerebral hemisphere in dogs, 
gave rise to movements on the opposite side of the body. 
The latter are movement complexes bringing into play 
several muscles concerned in various movements or acts 
and not individual muscles. Thus, the effect of injury to 
a definite area of the cerebral cortex is the inability to 
execute particular movements or acts. 

*The author's reference to this subject is in the nature of a preliminary report. 
Its intimate relation to the vertebral reflexes (page 7) justifies its consideration. 
It has only been investigated physiologically, but its possibilities in clinical 
pathology are far-reaching. 

383 



S p 



P y 



Our knowledge concerning the psychomotor area in the 
cerebral cortex emanates from the following sources: i, 
Experiments upon the cerebral cortex of monkeys; 2, Electric 
stimulation of the cortex in human subjects during the 
progress of a cerebral operation for the object of localiang 
a diseased area; 3, Clinical observations confirmed by 
autopsy in cases of cerebral tumors and Jacksonian epilepsy. 




Fic. 97. — Localization of Ihe moior area. This may be determined approii- 
matcly by drawing iwo perpendicular lines, one from ihe depreasbn in from ol 
ihe cxlcmal meatus, and the other from the pcsterior border of ihe mastoid process 
at its root; t. most prominent pan of parietal eminence. 

It has already been shown that spinal muscular reflexes 
could be elicited by sinusoidalization of definite spinal 
segments (page 11), and it occurred to the author that the 
motor area of the cerebral cortex could be similarly in- 
fluenced. That this is true is evidenced by execution of 
the following method: Having cocainized the skin of a 
bald-headed individual, corresponding to the motor area 
3S4 



Cortical Sinusoidali^^ation 

(Fig. 97), a powerful sinusoidal current (rapid sinusoidal 
from the Victor or the Kellogg apparatus) was conveyed 
to the motor area either by an interrupting bipolar electrode 
or with one interrupting electrode over the motor area and 
the other over the sternum. By opening and suddenly 
dosing the circuit, muscular contractions were observed in 
the muscles of the face, arm and leg on hoik sides of the 
body. Later, it was foimd that local anesthesia was un- 
necessary to obtain contractions of the muscles of the face 
and arm. It is better to employ a bipolar interrupting 
electrode over the motor area to exclude from participation 
in the muscular contractions the motor areas of the cord. 

One must not conclude that because the co-ordinated 
movements do not occur exclusively on the opposite side 
of the body, the clinical observations of the author do not 
correspond with the physiologic evidence. 

On the contrary, stimulation of an area on one side in 
animal experimentation results in bilateral movements in 
the case of corresponding muscles on opposite sides of the 
body that usually act together. Thus, Exner contends that 
such muscles appear to have a center not only in the opposite 
but also in the hemisphere of the same side. All observers 
have noted that stimulation of the facial center results in 
identical movements on both sides of the face. 

It has always been a question with physiologists whether 
similar areas exist in man. If the evidence adduced by the 
author is suflScient, the question may be answered in the 
affirmative. 

By placing one electrode of a slow sinusoidal current 
(Victor apparatus) over the sensory area (Fig. 97) and the 
other at an indifferent point and using a strong current for 
about ten minutes, a moderate grade of hemianesthesia 
may be produced on the opposite side of the body. Both 

38S 



Spondylo therapy 

sides of the body may be similarly anesthetized by fixing 
the electrodes on either side of the cranium corresponding 
to the psychosensory centers of the cortex. 



386 



The R e f I e X e 



DHBBBB^B^BB:B3BE^SaaBBBBai^BB 



CHAPTER Xn. 

THE REFLEXES* AND THE PERIPHERAL SYMPTOMATOLOGY 

OF VISCERAL DISEASE. 

Purport of spondylotherapy— general features of reflexes 
— therapeutics of reflexes — ^therapeutics of concussion 
—comparison of methods — ^trophic functions of cord — 
trophic diseases — ^peripheral reflex phenomena — ^insuf- 
FICIENCY OF THE FOOT — TEST FOR THE SPLANCHNIC CIRCULATION 
— REFLEXES OF THE CRANIAL NERVES. 

THE PURPORT OF SPONDYLOTHERAPY. 

TT7HEN the author first suggested the neologism, spon- 
^^ DYLOTHERAPY, he anticipated no misconception con- 
cemmg its object, yet "The Journal of the American 
Medical Association" conceived the foDowing analysis of 
the work in question : 

^^One wonders whether this is an attempt to explain^ 
osteopathy and chiropractic to the understanding of the regular 
practioneTf or to exploit the very ingenious percussion devices 
of the author J or whether it is really true that medical men^ 
really know practically nothing about the cure of disease 
through treatment of the spine. Let us hope that it is the latter , 
and that a careful study of this unique volume may open new 
avenues of therapy heretofore undreamed of^^ 

Now, osteopathy is a system which concerns itself with 
anatomic abnormalities and their correction. "Its nosology 
is a lesion, its symptomatology a subluxation." 

*The reader should consult the index to find the fundamental facts concerning 
the visceral reflexes. 

387 



p 



S p n d y I t h e r a p y 

Chiropractic presumes disease to emanate from displaced 
vertebrae. 

The Spinal centers are referred to in osteopathic and 
chiropractic textbooks, "with a dogmatism and certainty 
begotten of beneficial results." 

Spondylotherapy concerns itself only with the excita- 
tion of the functional centers of the spinal cord by different 
methods which may be executed and demonstrated with the 
same certainty in the living human subject as is done by the 
vivisectional experimentalist. (This phase of medicine is 
referred to by the author as "Clinical Physiology.") In 
brief, Spondylotherapy is based on the clinical physiology ol 
the human, in contradistinction to the study of physiology 
by the laboratory vivisectionist. Thus human, and not 
animal physiology, is made the basis of clinical pathology. 
In this way one has disproved by clinical observation many 
apodictic data created in the laboratory. 

Whereas spondylophysiology concerns itself with a study 
of the spinal reflexes, the therapeutics of the latter is embraced 
by the designation, spondylotherapy. 

Sponcylopathology. — Life is expressed by a rhythmic 
flow of automatic functions known as reflexes. Each reflex 
has its antagonistic reflex and, when both are co-ordinated, 
the result is a physiologic condition. 

When they are in a state of inco-ordination, the result is 
a pathologic-physiologic condition. According to this con- 
ception of spondylology, pathology is founded on physiology, 
and pathology is nought else but the physiology of the sick. 
Thus, a pathologic-physiologic condition creates its own patho- 
logic anatomy. That is, instead of regarding the morbid 
tissue-change as a primary requisite of disease, it is in reality 
secondary to physiology in a state of disequilibration. The 
real object of the practice of medicine is to cure disease 



I 



The Reflex 

it is only the doctrinaire whose fealty invokes the Skodaic 
pessimism: "We can diagnose disease, describe it, and get a 
grasp of it, but we dare not by any means expect to cure it." 
Thus the soulless philosophy which is too generally accepted 
as scientific medicine permits the scientist to diagnose 
diseases while the charlatan cures them." 

Conservative medicine is too often a practice of trusting 
to nature and confirming the diagnosis at the autopsy. 

We are inclined to forget the Hippocratic allusion to 
medical art; that it consists of three things — the patient, his 
malady and the physician. 

This is the era of therapeutic medicifie, and he who prates 
about the bankruptcy of therapeutics, substitutes the guinea- 
pig for a human and the laboratory for the bedside. 

Therapeutic nihilism owed its conception to the path- 
ologist, who sought to identify every disease with definite 
anatomic changes, and his coadjutor, the clinician, studied 
disease only in relation to these anatomic conditions. Thus, 
the clinician perpetrated the egregious mistake of associating 
the autopsic findings with the previous disease, whereas, as 
a matter of fact, the anatomic changes were sequential 
to the disease and not the disease itself. In other 
words, a perturbed physiology created its own pathologic 
anatomy. 

One of the most epoch-making developments of modem 
medicine is "Physiologic Therapeutics," which regards 
disease as an expression of morbid physiology and all that 
affects health, affects disease and that, to promote recovery, 
one must influence the general health. 

That disease is nought else but physiology gone mad is 
illustrated in bacteriotherapy and in our modem conception 
of semeiology. Thus, the inutility of bactericides in the 
treatment of infectious diseases led to an investigation of the 

389 



S P 



n d y I t h 



r a p y 



latter from a new view-point, viz.: How docs the organism 
deal with infections? 

It was soon demonstrated that the organism possessed 
chemical defenses and, as a consequence, modem bacter- 
iotherapy developed the therapeutics of immimity by utilizing 
as antitoxins the same products which the animal organism 
developed to combat infection or, by attempting to stimulate 
the organism to an augmented production of such defensive 
agents. 

Again, we have misinterpreted defensive reflex phenomena 
as symptoms of disease. Thus, hyperemia, long regarded as 
a symptom, is now utilized as a valuable physio-therapeutic 
method. 

Muscular spasm, by inmiobilizing a diseased joint or 
spine, or by protecting a sensitive viscus, is an expression of 
defense. 

Fever is probably a salutary process, for by this means 
the infected body is "cleansed by fire." Pathogenic bacteria 
thrive best at the normal temperature of the body and they 
either die or lose their toxic properties with the commence- 
ment of fever. The micro-organisms of malignant pustule 
cannot survive a temperature above 104'^ F., and thus can- 
not infect birds, whose normal temperature exceeds this limit. 
This immunity however, is destroyed if the temperature of the 
bird is reduced artificially. Our present conception of fever 
is in accord with the teaching of Hippocrates, that fever is a 
remedy. That it is "a reaction of the organism striving for 
a useful end, but that this end may not be reached or that 
it may be overstepped." 

General features of reflexes. — ^Reflexes function- 
ate with machine-like regulation {regulative reflexes'), and are 
usually automatic, i. e., independent of our own wills. If 
one stimulates the nerve of taste, there is a reflex secretion 
390 



The R e f I e x e s 

of saliva and gastric juice. However, one dare not exclude 
a psychic factor in the mechanism of reflexes. Thus, the 
mere sight of food causes a secretion of gastric juice; the 
heart is influenced by emotions, and definite psychic condi- 
tions influence the flow of urine. One of the most important 
objects of the reflexes is to protect the body from external 
injuries. The protective movements of pithed or decapitated 
frogs are so purposive in character and so co-ordinated that 
Pfluger regarded them as directed by and due to ^^conscious- 
ness of the spinal cord.^^ 

Just as will may excite a reflex, it may also prevent it 
(inhibition of reflexes). Thus, at well-regulated sanatoria 
for consumptives, one rarely hears a cough. There patients 
are disciplined to inhibit a cough and are informed that to 
cough in public is as much a breach of etiquette as to scratch 
one's head when it itches. It is still dubitable whether there 
are definite inhibitory centers or whether there are special 
afferent inhibitory nerves. 

As a rule, a reflex is more easily discharged by stimulation 
of the peripheral end-organ than by stimulation of the cor- 
responding afferent nerve-trunk. Even though recent phy- 
siologic investigations show that some of the secretions 
are not reflexes in the sense that they are mediated by the 
afferent nerves, yet in a general way they are still reflexes. 
It has been shown that the ductless glands elaborate specific 
chemical products known as hormones^ which are manufac- 
tured in one organ of the body and are conveyed by the blood 
to another organ or organs where they stimulate physiologic 
activity by their presence. 

Generally the reflexes are local, i. e., they are discharged in 
the region of the body irritated. If the reflex irritability is in- 
creased or if the stimulation is severe, the reflexes may be diff- 
used to regions remote from the area irritated {reflex dispersion). 

391 



S p n d y I 



t h 



a p y 



Okigln of the reflexes.— The former view that the 
spinal cord was the center of all reflexes is doubtful and the 
following classification of reflexes by Jendrassik is worthy of 
consideration : 

1. Spinal Reflexes, include tendon, periosteal and joint- 
reflexes. They are usually discharged from areas mih 
diminished sensation ; are dissociated with any special feeling; 
mechanic irritation (like a blow) sufiices for their dischai^; 
the intensity of the reflex is based on the degree of irritation 
and not upon its duration; making other muscles tense 
augments the reflex (Jendrasslk's method of reinforcement); 
the reflexes are augmented when attention is distracted. 

2. Cerebral Reflexes include the cutaneous reflexes, and 
they are discharged from sensitive areas. Unlike the spinal 
reflexes, they are increased or diminished by psychic in- 
fluences and distraction of the attention impairs them, 

3. Complex Reflexes include such which are made up of 
a series of movements like coughing, sneezing, vomiting, 
defecating, etc. They are discharged by protracted stimu- 
lation {summation of stimidf) ; the reflex involves different 
groups of muscles and even antagonistic reflexes and psychic 
influences are of greater moment than with the cerebral 
reflexes. 

Therapeutics of the reflexes.* — When the oculist 
contracts or dilates the pupil, he employs reflexes in treat- 
ment. Contraction of the pupil is controlled by the oculo- 
motor nerve, which supplies the sphincter pupillae (and 
ciliary muscle), and dilatation of the pupil is governed by the 
sympathetic. Thus eserin, which stimulates the oculo-motor 
nerve contracts the pupil, whereas atropin, which paralyzes 
the same fibres, dilates the pupil. Thus, in iritis the most 



•The phannacology of the reflexes is discussed in Chapter XIIL 
392 



The Reflex 

important remedy is atropin, because among other effects, 
the eye is put at rest, owing to paralysis of the sphincter. 

The day is fast approaching when improved methods of 
spinal nerve- trunk analgesia (page 382) will enable us to 
inhibit or excite reflexes to cure disease. Surgery has already 
invaded this field in the treatment of spasticity , by resection 
of the posterior spinal-roots (rhizotomy). Here, the object 
is to inhibit afferent impulses from the muscles which excite 
the cells of the anterior horns of the cord to send out excessive 
motor reflexes to the muscles. 

In the therapeutic elicitation of the spinal reflexes one 
must take cognizance of the physiologic data which are 
applicable clinically: 

1. A stronger stimulus is necessary to excite a reflex 
movement than for the direct stimulation of motor nerves. 

2. A reflex movement is of shorter duration than the 
same movement executed voluntarily and there is a decided 
delay after the moment of stimulation. The reflex time 
diminishes as the strength of the stimulus increases. 

3. Stimuli must be regarded as various forms of energy 
and overstimulation conduces to exhaustion, when even a 
powerful stimulus fails to elicit a response. 

In other words, weak irritation augments the irritability 
of the spinal centers; medium irritation benefits them; 
strong decreases; and very strong abolishes the irritability. 

Some of the failures in my early practice in the appli- 
cation of spondylotherapy were due to overstimulation of 
the spinal-centers. Now, I make short and interrupted 
stances, a fundamental principle in treatment. Several 
treatments may be given daily but they must be of short 
duration. The physiologist employs electric in preference 
to mechanic stimuli for the reason that they are easily applied 
and their intensity controlled. He has conmiitted himself to 

393 



the Galvanic or Faradic current for electric stimulation and 
the sinusoidal current receives no consideration in the text- i 
books on physiology. 

In my animal experiments I found the sinusoidal current 
used percutaneously, the only effective one for elicitation of 
the visceral reflexes. With the use of strong currents over 
definite vertebral regions, practically every viscus could be 
made to contract or dilate at will. 

In association with contraction, the organ became anemic 
and conversely, hypercmic when the organ was dilated. 
These circulatorj- modifications were due no doubt to the 
visceral musculature and were quite independent of any 
action on vasomotor centers. 

With repetition of sinusoidalization, however, the nsceral 
reflexes became exhausted and even the strongest stimulation 
was without effect. After a period of rest one could again 
elicit the reflexes in question. 

Therapeutics of conxussion. — My observations on 
concussion, as presented on pages 175 and 380, have been 
further exploited. No reliance can be placed on the average 
concussion apparatus; it is what it is intended to be, a mere 
vibrator. The apparatus which the author emplo)'s (Fig. 50), 
operates with an average pressure of 40 pounds and yields 
a blow equivalent to 1 2 pounds. Unfortunately, this appar- 
atus is noisy and compressed air is not alwa>'s obtainable. 
To obviate these difficulties the author has devised an effi- 
cient electro-concussor. 

Methods are frequently discredited for the reason that 
they are faultily executed. 

A physician employed the author's method for several 
months in a case of aneurysm of the thoracic aorta without 
results. The patient got progressively worse and the con- 
dition was apparently hopeless. My colleague had employed 



The Reflexes 

^HHHiBHHI^IB9HI^^BBBBS^BBB^^^^&B&SBBSSIBI^^B^B9BSBBS9HS8HHBB9BBB9^S^^SBBBB 

a mere vibratory toy for treatment. Within a few stances, 
after vigorous concussion of the seventh cervical spine, the 
patient began to progress rapidly toward recovery. The 
author has repeatedly demonstrated that vibration will not 
elicit a visceral reflex, hence it is of no avail in treatment. 
In the absence of a trustworthy apparatus, the method 
shown in Fig. 2 should be used. Several physicians have 
successfully employed the latter method exclusively in the 
treatment of aneurysms. 

Some physiologists deny the excitability of the spinal 
cord and attribute any reaction to stimulation of the roots 
of the spinal nerves. On page 170 (Fig. 48), reference is 
made to the elicitation of visceral reflexes by paravertebral 
pressure* Now, if one compares the results of pressure 
with a special instrument (Fig. 112), at definite paravertebral 
areas, with concussion executed in the usual way (concussors 
applied directly to the spinous processes), the following 
results were obtained in the same subject, with the stomach 
reflex of contraction : 

After five minutes concussion of the first lumbar 
spine the amplitude of the reflex was 2 cm., and its dur- 
ation, one-half minute. After pressure on both sides of 
the first lumbar spine for one-half minute, the amplitude 
of the reflex was 3 cm., and its duration, 15 minutes. 
Here, the results were clearly shown to be due to nerve- 
trunk stimulation and not to segmental excitation. 

Later, the author evolved a special kind of metallic 
concussor, as shown in Fig. 98, which concusses both 
sides of the spinous process, instead of direct concussion 
of the latter. 

This concussor fitted into the pneumatic hammer, or the 
apparatus of the author, elicits visceral reflexes of greater 

*Vide Chapter XIII for a more extended discussion of this subject. 

395 



S p 



t h 



a p ■$ 



amplitude and of longer duration than when the spines a.Tt 
directly concussed. 

Slow and rapid concussion. — The physiologist attaL^fi 
different results from stimulation according to whether fr "he 
stimulus is applied rhythmically at a slow or rapid ra_ "U;. 




Fig. ^. — Concussor which delivers blows lo both ^desof a, spinous pm 
It is of melal and covered with layers of felt and rubber to eliminate any p 
n resulting from coneuaaion. 



My clinicaJ results are in accord with the foregoing obs 
vation. 

Thus, a liver by percussion measures la cm.; after 
rapid and continuous concussion, it measures 8 cm., and 
after slow and interrupted concussion -blows, it is still 
further reduced to 6 cm. After concussion of the first 
three lumbar spines to elicit the stomach reflex of con- 
traction, rapid blows caused a recession of 1.7 cm. of the 
lower border of the stomach, whereas slow and inter- 
rupted blows resulted in a recession measuring 3.5 cm. 

In this, as in all other recorded observations, the 
same blow and pressure were used and the duration of 
treatment was the same. For the purpose of contracting 
the viscera, slow and interrupted concussion-blows axe 
more efficient than rapid and continuous blows. 

396 



The Reflex 



^■BBBB 



To secure dilatation of blood-vessels, the slow and 
interrupted concussion-blows, are equally more efficient. 
Thus, in an aneurysm which has a transverse diameter 
of 6 cm., rapid and continuous blows to elicit the aortic 
reflex of dilatation increase the diameter to 8.3 cm., where- 
as slow and interrupted blows increase the diameter to 
9.5 cm. 

To contract blood-vessels (and aneurysms), rapid 
and continuous blows are more efficient. 

Thus, an aneurysm with a diameter of 7 cm., is, after 
slow and interrupted blows to elicit the aortic reflex of 
contraction, reduced to a transverse measurement of 
5.8 cm., whereas, after rapid and continuous blows, 
the transverse diameter is reduced to i cm. 

Comparison of methods. — It is only possible in a 
general way to say what is the most eflScient method for elicit- 
ing the visceral reflexes. 

Like all cells, the neurones do not react to the same 
stimxilus. Electricity with weak currents increases, and 
strong currents decrease the activity of the cells. 

Unfortimately few physicians are sufficiently skilled in 
percussion to determine for themselves the best method to 
employ. Very often the rapid sinusoidal current is more 
efficient than concussion. Thus, in a patient with an aortic 
aneurysm, the following comparative results were obtained 
in eliciting the aortic reflex of contraction : 

METHOD. DURATION OF TREATMENT. DURATION OF REFLEX. 

Concusnon. x min. to 7th cervical 13 minutes. 

spine. 

Rapid ^uaddal cunent. x min. to both sides of 36 minutes. 

same spine. 

STOMACH REFLEX OF CONTRACTION. 

METHOD. DURATION OF TREATMENT. DURATION OF REFLEX. 

4 

Slow blows directly to One-half minute. 3 minutes and 35 seconds, 

spinous process. 

Slow blows to both sides One-half minute. 16 minutes. 

of spinous process. 

Slow nnuaoidal current to One-half minute. 8 minutes. 



to both ndes of spine. 



397 



S P n d y I 



t h 



a p y 



VASODILATOR LUNG REFLEX 
(Application to ihe loth dorsal spine. 



minute. 



45 seconds. 

No tesulL 






Concussion. 

Rapid wniisoidal current. 
Slow sinusoidal current. 
Higb-trequency tufreni. 
Paravertebial pressure. 

VVhen pressure exceeded one minute, the dullness was d sfaoit duolloti. 
reflexis are more lasUy txhausUd b> freisurr iHan by any rHktr molui. 



For discharging visceral rcSezes, the rapid si 

efficient than ihe slow current. WUh different anusoidal n 
discordant results. 



ichit 




-The- Mcintosh polyaine generator. 



"This cellex is fully discussed in Chapter XVT, page 606, and is associated 1^ 
dulln— • if the lung. Here, du^a(Hm0/rc^» refers to the duiatiOD of duUoes. 



The Reflex 



SB 



In my investigations, the Polysine Generator (Fig. 99), 
made by the Mcintosh Battery and Optical Co., of Chicago, 
was employed. The dial selector attached to this apparatus 
obviates the necessity of learning by rote the operation of 
the many switches in order to obtain the required combi- 
nations. 

The high-frequency current, applied by means of a double 
vacuum electrode (Fig. 100), to either side of definite spines, 





Fig. 100. — Double Vacuum Electrode. 

will elicit visceral reflexes of great amplitude and long dur- 
ation. For this purpose, in some instances it is more effective 
than the other physio-therapeutic methods.* 

The visceral musculature is of the non-striped variety, 
which is more easily fatigued than striped muscles. Exces- 
sive stimulation of muscle results in degeneration of the 
latter. If a muscle is stimulated by maximum induction- 
shocks imtil it ceases to contract, its excitability may be 
restored by massage, the constant current, veratrin, per- 
manganate of potash, or rest. 



♦The author has Investigated the Leduc (direct interrupted current of low 
tenaon) and ikermopenetrating currents, and finds them of no value in the elicita- 
tion of visceral reflexes by vertebral excitation. 

399 



S p tt d y I 



t h 



a p y 



The foregoing facts may be illustrated clinically in ihe 
use of physio- therapeutic methods. Thus, if the visceral 
reflexes can no longer be elicited after the prolonged use 
of one method of excitation, another method may evoke 
a response. 

In a patient with a large aortic aneurysm every 
symptom had practically yielded in about two weeks to 
treatment by concussion, excepting a slight cough. 
Recourse was then had to the rapid sinusoidal current on 
dthcr side of the seventh cervical spine and within a few 
days this vestigial symptom of the disease disappeared. 

An elderly gentleman was practically moribund on 
two occasions and was restored to comparative comfort 
by concussional treatment. A slight dyspnea on exertion 
with a rapid pulse persisted despite treatment. Within a 
tew days after daily hypodermic use of stropbanthin, 
dyspnea and tachycardia disappeared. This same drug 
prior to concussional treatment was ineffective. Thus, 
drugs must be employed as succedanea for physio- 
therapy and the latter for drugs. 

Trophic FUNcnoNs of the spinal cord. — Aside from' 
the function of the cord as a. conductor of impulses, one mtist 
not disregard its puissant function of presiding over muscular, 
cutaneous, osseous and arthritic nutrition. The trophic 
control is probably resident in the gray matter. Lesions e 
the lower motor neurone cause atrophy or dystrophy of the 
muscles. To question the existence of trophic nerves is a 
mere matter of logomachy. Suffice it to say that the nerve 
cells of the cord maintain the normal state of nutrition a 
the organs and tissues and implication of the cells predicate 
definite trophic disturbances. 

Cell-stimulation. — The essential principle of livinj 

substance is its property of altering its metabolism juic 

transforming its energy. This principle is known as irrit^-. 

biliiy, and the agents which can excite it (heat, light, electri 

400 



The Reflexes 

city and chemic and mechanic agents), are known as stimuli. 
The metabolic change resulting from stimulation may 
develop kinetic energy and the cellular condition is known as 
excitation, or potential energy is developed and the cellular 
condition is known as its trophic effect. 

Stimuli which may evoke the former propitious effect 
may also check metabolism (cellular paralysis). The follow- 
ing observations on cell-stimulation are axiomatic: 

1. The development of energy is greater than the 

energy of the stimulus used. 

2. Cells summate the effects of stimuli. With a rapid 

succession of stimuli, contractions may be evoked 
which are stronger than that obtained by a single 
stimulus. 

3. Cells always react in a specific way, irrespective of 

the nature of the stimulus; a muscle-cell responds 
with contraction; the cell of a salivary gland will 
secrete saliva. 

4. Stimuli are transient in their action and overstimu- 

lotion always conduces to exhaustion. I have italic- 
dzed the latter fact to emphasize its importance. 
It applies with equal cogency to pharmaco-, or 
physio-therapy. 

TROPmc DISEASES. — ^There are a niunber of diseases 
characterized by nutritional disorders in which the lesion 
is probably resident in the gray matter of the cord or in the 
peripheral nerves (which comprise the lower motor neurons 
presiding over nutrition). The trophic impulses usually 
traverse the motor nerves. It is only necessary to mention 
several trophic diseases in which I have employed concussion 
as a mechanic aid to cell-stimulation. 

Arthritis deformans.* — This disease is recognized by 
the following: 



*Tlus affection is likewise discussed on page 105. 

401 



S p 



d y I 



t h 



r a p n 



1. Muscular atrophy precedes the involvement of the 
smaller and unusual joints (maxillary articulation, fingers, 
toes). 

2. Presence of trophic or pigmentary lesions m jiirta- 
position to the implicated joints and stiffness or soreness 
antedating the actual inflammatory changes. 

3. Persistence of the condition when a joint is once 
attacked. 

4. The negative action of the salicylates (page 142), and 
the infrequency of endo or pericarditis excludes rheumatism, 

5. Gout is excluded by the absence of movable deposits 
of sodium urate in the soft parts beneath the skin. In the 
monarticular form of arthritis deformans, large joiots 
(shoulder, hip, knee), may be involved. When the hip is 
involved, it corresponds to the condition known as morbus 
coxae senilis. 

It is usual to regard arthritis deformans as a chronic 
infection, an hypothesis which has supplanted the \iew once 
held that it was associated with lesions of the spinal cord. 
In accordance with this theory, I have employed concussion 
of definite vertebrae. While my results have not been 
phenomenal and I have not restored the shape of crippled 
joints, pains were subdued, a modicum of function was 
restored to the joints and I believe the progress of the disease 
was arrested. 

In 1831, Prof. K. Mitchell, associated this affection with 
lesions of the ganglion-cells of the anterior horns (congestion) 
and he successfully treated this and chronic forms of rheu- 
matism by cupping and blistering. From 8 to 16 ounces of 
blood were abstracted from the regions corresponding to 
the cervical (upper extremities affected,) or lumbar enlarge- 
ments (lower extremities affected). When cupping was 
unsuccessful, blistering was employed in the same regia 
402 



The R e f I e X e 



^t^tm 



Latham**^, and others, have recently reported brilliant 
resxilts in hopeless cases following thorough and repeated 
blistering. 

Freezings in my experience, is more eflScient and less 
troublesome than blistering. Unless the results are inuned- 
iate (less pain and stiflFness), nothing can be expected from 
repetition of the treatment. When the upper extremities are 
involved, one should freeze in the region of the cervical 
enlargement of the cord (3d cervical to 2d dorsal vertebra), 
and to influence the lower extremities, the entire region cor- 
responding to the lumbar enlargement (9th dorsal to ist 
limibar vertebra) should be frozen. 

The employment of dry hot air in this disease has been 
highly conmiended by a number of observers. However, to 
be eflScient, the air must attain a temperature of from 350® 
to 400® F. A lower temperature gives indifferent results. 

Thermotherapy is often discredited for the reason that 
the amount of heat applied to a part is insuflScient. The 
fact of the matter is that as long as the peripheral circulation 
is maintained, neither extreme heat nor cold shows pene- 
trating power of sufficient practical value. The latter objec- 
tion I have often obviated by making an extremity anemic by 
aid of a rubber bandage. 

When a multiplicity of remedies are reconmiended for 
an individual disease, it is less a reproach to physiologic 
pharmacology than it is to pathology. The latter, for many 
diseases, is not definitely established and it varies according 
to the stage of the disease and the reaction of the individual. 

Among the physio-therapeutic methods which have 
recently enjoyed therapeutic renomee in the treatment of 
arthritis deformans and other affections, is thermopenetra- 
tion. 

Insoniuch as the latter has given excellent results accord- 

403 



S p n d y I 



t h 



r a p y 



ing to a. method original with m3rself, I shall give it special 
consideration. 

Diathermic spondylotherapy. — The local application 
of heat has always been recognized as a valuable empiric 
method of treatment. 

The physiologic action of heat is produced by irritation 
of the cutaneous nerve-endings manifested by dilation of 
the blood-vessels, augmented functionation of the sweat- 
glands with increased local elimination, improved nutrition 
of the tissues and changes in the cellular metabolism restilting 
from the increased temperature of the part. 

Perhaps the most important physiologic action of heat 
is to produce hyperemia. The latter is nature's own remedy 
and occurs with the regularity of a natural law. 

Among the effects of hyperemia are: Relief of pain, 
bactericidal action, resorption property of dissolving blood- 
coagula, exudates in joints and tendons, etc. 

Heretofore, the different methods employed for raising 
the temperature of the subcutaneous tissues suffered the 
drawback of injuring the skin. The latter is a very poor 
conductor of heat and investigations show that it is practically 
impossible to raise the temperatures of the subcutaneous 
structures by the conventional methods of using heat to the 
skin. 

It has been found that a high potential oscillating current 



The Reflexes 

of the subcutani^us structures is known as diathermy, trans- 
thermy and thermo-penetration. In the conventional use 
of diathermy, notably in affections of the joints, the electrodes 
are applied opposite each other and the current is used to 
the point of toleration as long as possible. The high-fre- 
quency current for diathermic purposes is devoid of chemic 
action provided sparking is prevented. 

In my experience, the heat generated by the current is so 
great that patients can only tolerate it for a very limited 
period of time. To obviate the latter objection, the sponge 
contacts are immersed previous to application in a satiuuted 
solution of ammonium nitrate. 

Applied directly to the aflfected joints in arthritis de- 
formans, there is a local reaction manifested by swelling, 
pain and stiflFness of the joint. This reaction is less accentu- 
ated with repetition of the treatment, which, if successful, 
yields results after a few stances. 

Better results in my experience, however, follow the use 
of diathermy to definite vertebral areas. 

As a rule, one finds sensitive vertebral areas on pressure 
corresponding to the joints involved and the electrodes are 
then applied on both sides of the spine. 

Lo(X)MOTOR ATAXIA. — The exact seat of the initial lesion 
in tabes is dubitable but there is every reason to believe that 
it is primarily an inflammation of the posterior nerve-roots or 
the ganglion-cells in the posterior ganglia are first implicated. 
In my experience, diathermy is practically a specific for the 
characteristic pains of this disease which follow dorsal root- 
areas. 

Figs. 92 and 93 show the vertebral sites for the application 
of the diathermic current. Thus, if the pains are located 
below the knees, the electrodes are placed on either side of 
the spinal column corresponding to the nth and 12th dorsal 

405 



Spondyloth 



r a p y 



spines. The same method is apphcaUe in pains of spinal 
origin which prove refractory to conventional treatment. 
Here, the morbid anatomy is practically identical with early 
tabes, viz., a radicular meningitis. 

The FDNcnoNAL spine.'" — In this condition, diathermy 
is also very effective. In the functional spine, pain is felt in 
the region of the lower dorsal and upper lumbar spine. It 
is in the nature of an ache and stiffness on attempting to 
straighten up &om a stooping posture or in getting up in the 
morning. Limitation of motion is caused by muscular 
spasm. 

Diseases of the Motor Tract. — Atrophic change in 
the motor neurons is the basic anatomic lesitm in these 
diseases and concussional treatment should be given a trial. 
In one case of Polio-Myelitis, in which both legs were 
affected and the paralysis had failed to yield to conventional 
treatment, an almost complete cure was effected by vertebral 
concussion. The affected muscles began to react to the in- 
duced current after twelve stances* 

If the lower extremities are implicated, concussion is 
executed in the region corresponding to the lumbar enlarge- 
ment (9th dorsal to ist lumbar vertebra). 

Beri-beri. — This disease, which is very prevalent in 
tropical countries, is characterized by motor and sensory 
paralysis and atrophy of the muscles. Among the clinical 




Reflex 



U. S. A. T. ''Seward;' 
Manila, P. I., May 7, 1910. 

''In answer to your letter of inquiry concerning my 
experience in the treatment of chronic beri-berif it gives 
me pleasure to inform you that remarkable results have 
been obtained by means of a series of concussions, made 
by the strokes of a rubber-tipped hammer, weighing 
about one ounce, on both sides of the spinal column, 
over the exit of the nerves supplying the parts of the 
body diseased.* The exact technique used is that des- 
cribed in your monograph, ''The Treatment of Aneurysm 
by Spinal Concussion." 

For a weak heart, concuss the nerve at its exit from 
the third dorsal; to affect the muscles above the knee, 
and calf of legs, concuss the nerves at their exit from the 
third and fourth dorsal, those of the plantar muscles, the 
nerves from the fourth sacral. As the hammer falls 
gently over the nerves near their exit from the spinal 
column, a play of the muscles may be seen successively, 
as each group is concussed. 

The patient arises from the stance with a sense of re- 
newed strength in the use of the muscles, which here- 
tofore had failed him in walking. 

There is improvement from the first treatment. 
Each treatment lasts about five minutes, and is given 
daily for five to twenty days. There is often some trouble 
in locating the nerve. Make exploratory taps and, when 
the expected reflex action shown by the contracting 
muscle is seen, it is well to mark the spot by a point of 
indelible ink.f Locate all the nerves it is desired to 
concuss; this having been done, dismiss the patient 
to return the next day. 

At the second and subsequent sittings, let tbe hammer 
play over each nerve — guided by the ink-spots; on 
first one and then the opposite side of the column, going 
up and down the column much as the fingers of the 

Vide Fig. 3. 

Caibol fuchsin is better for dermography 

407 



piano player following the scale on the while and black 
key-boards. Tap with the hammer genily. with just 
sufficient force to cause the muscles lo respond. 

My experience has been limited to six cases. The 
first, a man 37 years, had beriberi five years previously. 
Ever dnce his recovery from the acute symptoms he had 
not been capable of continued exertions for more than a 
few minutes without feeling a fainting sensation. The 
only organic trouble discernible was a distinct hemic 
murmur of the heart. He had taken the usual tonics 
with but little effect. I proceeded to concuss the nerves 
on both sides of the spinal column only opposite the third 
dorsal vertebra. The effect was beneficial. .A^fter the 
seventh sitting he declared himself well. His hemoglobin 
COtmt had risen from 60 to 80. I saw him a month later, 
the picture of health and no murmur noticeable. 

The third case was a soldier, ai years old, who had 
beriberi eighteen months previously, was returned to 
duty after a month in the hospital but was unable ever 
to do full duty. Ulien I saw him his captain had just 
forwarded a request for his discharge. He could not 
make more than two or three hundred yards without 
"falling out," because of weakness of his knees, legs and 
feet. Treatment was begun at once with the result that 
within two months he was doing full duty, even to scaling 
a 12-foot wall. In not one of the six cases was any 
medicine used. Good hygiene and proper food were the 
only synergists used. In one only, the heart symptoms 
predominated. The other five had the lower extremities 
affected, and of these five, three were cured, the other 
two markedly improved. 

Wishing you every success in your pioneer work 
lo make scientific the treatment of chronic and heretofore 
incurable affections resulting from apathetic conditions 
of the nervous system, 

I remain very sincerely, 
G. W. Davwalt. 

is! Li. Med. Res. Corps, V. . 



The Reflex 



BBHBBSa 



Beri-beri is essentially a multiple neuritis and concussion 
is indicated in the latter disease after the acute S3rmptonis 
have subsided. 

Therapeutic-Physiology of Concussion.* — ^Numer- 
ous correspondents have solicited further information con- 
cerning this subject. What is said of concussion refers with 
equal cogency to other methods for eliciting the visceral 
reflexes and, if aneurysm is selected as a paradigm, it is 
because it has been made the subject of the most frequent 
interrogation. 

The balneologic treatment of heart-disease by Nauheim 
baths has shown itself to be of great value and is based on 
soimd physiologic principles. Schott, who inaugurated this 
treatment suggested among other things, that the good 
results were due to a reflex stimulation of the heart which 
evokes slower and more powerful contractions of the organ. 
In other words, one elicits by this method the heart reflex 
as suggested on page 218. 

Muscle Tonus refers to a continuous (however slight) 
contraction of muscle under normal conditions and which is 
maintained by subminimal nerve-impulses constantly dis- 
charged from nerve-centers into the muscles. In this way, 
the neuro-muscular apparatus is in a condition of tonic 
activity. Thus, the sphincters in the norm are in a state of 
tonic contraction. Tonus is of the greatest importance in 
clinical medicine as we shall learn in chapter XIII. It 
is most probably maintained by the direct stimulating effect 
of the internal secretions upon the peripheral organs or 
upon the central or peripheral nerve-cells. 

That tonus may be augmented from the periphery is 
illustrated when the skin becomes chilled. Here, the sensory 
stimulation thus evoked, reacts upon the nerve-centers and 

^Reference has already been made to this subject on page 267. 

409 



S p 



I 



t h 



P 3 



the discharge along the motor paths to the muscles causes 
the discernible movements of shivering. 

It is in this way that one may explain the elicitation of 
visceral reflexes either by peripheral or central stimulation 
(vertebral reflexes). We shall also learn in chapter XIII 
that tonus may be Influenced by psychic factors. Let us 
in our polemic concede that the foregoing holds as far as 
musculature is concerned. In the aorta, however, the 
limica media (middle-coat), in comparison with the coat of 
other arteries, Is thicker and contains relatively more elastic 
and less muscular tissue. In the root of the aorta, this coat 
consists chiefly of striated muscle (like that of the pulraor 
artery), and resembles that of the myocardium with wla| 
it is continuous. 

The contractility of the aorta, however, is a question' 
physiology and not histology. 

The majority of writers contend that mesarteritis resi 
ing in degeneration of the elastic tissue of the aorta is the 
predisposing cause of aneurysms,* 

Experimental aneurysms result when the wall of an 
artery is cauterized ; the resulting inflammation causing the 
formation of fibrous tissue without elasticity and the latter 
being less resistant than an elastic tube, dilatation of the 
vessel ensues. 

In small sacculated aneurysms, a spontaneous cure has 
been known to occur by thrombosis. In our many successful 
symptomatic cures of aneurysms, we have not had an oppor- 
tunity of determining the rdle played by thrombosis, hence 
the doctrinaire must await the verdict of the necropsy. We 
believe that our results are achieved by increasing the 
tonicity of the vagus {vide chapter XIII), which in reacting 
on the fibro-muscular coat of the aorta diminishes the 



coat 
inary 



*As will be ibawn o 



. page 552, the author j 
410 



□ accvid with Ihis view-pa 



The Reflexes 

caliber of the vessel and by augmenting its elasticity makes 
it more resistant (Fig. 119). The results attained are not 
unlike the effects on the heart by the methods of Schott. 
The physiologic excitation of the aortic and other visceral 
reflexes increases the contractility and tonicity of the aorta 
and viscera but when the stimulation is excessive, the 
opposite effect is produced^ viz. : dilatation and diminished 
contractility and tonicity. 

Peripheral Reflex Phenomena of Visceral Disease. 

I. Pain; 2. Hyperalgesia; 3. Muscular Spasm; 4. 
Secretory reflexes ; 5. Vasomotor reflexes ; 6. Pilo-motor 
reflexes; 7. Paravertebral tenderness; 8. Elevation of 
temperature. 

Before consideration is given to the foregoing symp- 
toms attention must be directed to the cerebro-spinal and 
to the autonomic nervous system* (P&ge 24) . The former 
system including the brain, spinal cord and the peri- 
pheral nerves mediates sensation and muscular contrac- 
tibn. 

The autonomic system innervates the viscera. 

Both systems are intimately associated and afferent 
impulses passing from the viscera stimulate the nerves 
of the cerebro-spinal system so as to eventuate in peri- 
pheral pain, hyperalgesia and muscular spasm. The 
autonomic system, according to Langley, is shown in 
Fig. loi. 



♦Further discussed in Chapter XIII. 

411 



S P 



d y I 



a p , 



Dilator of im. Orbital muBcU. 
HoBrt. Blood-veaaeU of muooua 

menibran« of liMd. 
Walla of ([ut from mouth to do- 

acending colon. 
Outgrowtha from thia region of the 

KUt (muBcle of trachea and 

iunga ; gsatric glands, liver. 



Tha akin (artoriei, muaclea, glanda). ' 
Blood- veaaela of gut betwenn 

mouth and rectum, of lungs 

and of abdominal viscera- 
Arteries of skeletal muscle. 
Muscle of spleen, ureter, and of 

internal generative organs. 
Walls of stomach, intectine, gall 

bladder and ducts, unnary 

bladder. 



Artenee of rectum, anus and \ 

external generative organs. | 

Walls of descending colon to end I 

Walls of bladder and urethra. 
Muscle of external generative I 



Fig. loj. — Illustrating the origin and distributbn of eSeicnt a 
"Muscle," refers to unstriated muscle only and the "walls" of a stnictuic sigi 
the unstriated muscle in them. The innervation of the gastric glands, panci 
and liver and the arterioles of the skeletal muscles and the central nervous sysl 
is still dubitable. 



Mid-bnia 
Bulbar 



The Reflex 



■B 



I. Pain. — ^When the cerebro-spinal nerves are stimu- 
^ted, the pain is referred to the peripheral distribution of the 
^^Tve. In many instances, however, the pain is not strictly 
^^^calized in the irritated nerve itself but it radiates to different 



Mackenzie^ quotes Sherrington, who states that, after 
Applying a mustard leaf over the front of the upper part of 
the sternum, an unpleasant tingling sensation was exper- 
ienced above the inner condyle over each upper arm. In 
explanation of this phenomenon, one knows that the second 
thoracic nerve supplies equally the upper chest and the 
inner side of the upper arm and that, when the stimulus 
from the chest (after application of the mustard plaster) 
reaches the spinal cord, it affects the adjacent cells. Hence, 
although the peripheral parts are widely apart, they have a 
common center in the cord. 

This overflow of the reflexes, or what is currently known 
as radiation of pain, is illustrated in daily practice and is 
often a source of error in diagnosis. Thus, one may cite 
abdominal pain. Palpate the abdomen almost anywhere 
and the pain is often as keenly felt in one as in another 
situation. In such instances, the pain without conspicuous 
associate symptoms may mean an appendicitis, and for that 
matter, it may just as well be the pain of biliary or renal 
colic, or if a woman be the subject, pelvic disease. Here the 
inhalation of chloroform, not to the point of anesthesia, but 
just enough of it to quiet the patient without affecting con- 
sciousness, causes the disappearance of radiating pains, 
^hile the original pain remains fixed in the region of the 
right hypochondrium in gall-stone colic, or over McBur- 
ney's point, in appendicitis. Morphin, hypodermatically, 
accomplishes the same object. 

In this connection, I wish to refer to another diagnostic 

413 



S p n d y I t h e r a p \ 

point. If one is in doubt concerning the organ as the sourco 
of pain, palpation or pressure on the implicated organ will 
reproduce the exact pain about which the patient complains. 
A fixed pain practicaUy always denotes an organic and not 
a functional lesion. 

In trigeminal neuralgia, I have frequently encounterai 
sensitive areas at the side of the ist and znd cervical spines, 
and freezing of the latter was followed by relief for a vari- 
able period of time. This also applies to odontalgia. A 
spinal tract of the trigeminus can be traced as far dovm as 
the second cervical segment of the cord. It is also easy to 
tinderstand vagal-refiexes in consequence of trigeminal irri- 
tation; at its cranial end, the vagus is in direct relation vrfth 
the trigeminus through the intervention of the Rjbercle of 
Rolando. 

Even under anesthesia, th« trigeminus maintains its 
sensibility and though sensation is abolished clsewhei 
punctures in the temples and frontal region are still ] 
ceived. 

Dr. Geo. Baert, of Michigan, having availed himself 3 
the foot-note su^estion on page 374, employed the treat- 
ment successfully in several cases of trigeminal neuralgia, 
notwithstanding futile results with injections of alcohol. 
An overflow of the reflexes is frequently noted in func- 
tional disturbances. Thus in hysterical anesthesia, there is 
a temporarj' restoration of cutaneous sensibility after the 
use of morphin hypodermatically. In hysteria, one also 
observes during the stage of chloroform excitation, the dis- 
appearance of contractures and other stigmata of the disease. 
One must not forget that spinal nerves are composite 
structures and spasm and pain are associated with their 
irritation. Thus, in laryngeal stenosis of children, the use of 
an opiate excludes the spasmodic element and often i 
+14 



I makoH 



Visceral Pain 

a tracheotomy iinnecessary. This same practice applies to 
the introduction of an instrument into the bladder when 
there is spasm of the vesical sphincter. 

Visceral Pain.* — Mackenzie contends that the viscera 
are insensitive to ordinary stimulation and what is regarded 
as visceral sensitiveness by the examining physician is merely 
cutaneous and muscular hyperalgesia. In other words, 
visceral pains are not felt in the organ, "but are referred to 
the peripheral distribution of cerebro-spinal nerves in the 
external body-wall." In support of his hypothesis, Mac- 
kenzie cites the following: 

1. Pressure exerted over a supposed gastric ulcer, an 
enlarged liver, or an inflamed pleura, causes pain; but this 
method of investigation ignores the augmented sensibility 
(h3Tperalgesia) of the tissues (skin and muscles) covering the 
external body-wall. 

2. Pain is felt in the position where the organ is situated. 
If this were true, then the pain would shift in accordance 
with the location of the organ. Thus, in gastric ulcer even 
though the stomach is dislocated by deep respiratory move- 
ments, the pain remains stationary. 

I contend that there is visceral pain sui generis but that, 
it may be associated with pain referred to the coverings of 
the body-wall connected with the same segments of the 
spine. The investigations of Mackenzie demonstrate that 
the viscera are only insensitive to such stimuli as pressing, 
drjring, application of silver-nitrate, burning, cutting, etc., 
and that, were a definite stimulus employed, visceral sensi- 
tiveness could be shown. It is known that a nerve-ending 
may respond to one form of stimulation and yet prove 
insensitive to others. Every nerve when stimulated responds 

♦Reference is made to this subject on pages 58 and 413. 

415 



in a manner peculiar to its function. Stimulation of the 
optic ncn-e creates the sensation of light and excitation of 
the auditory nerve responds with the sensation of sound. 
The recent investigations of Hertz** show that tension is the 
only cause of true visceral pain and that pain originating 
in the peritoneum* is not uncommon in the absence of 
visceral pain. 

In a patient where the diagnosis of gastric ulcer was 
definitely established, the skin and muscle in the region of 
a sensitive point were anesthetized yet, by deep pressure, 
I succeeded in eliciting the same degree of tenderness as 
before local anesthesia. 

By ray method of transmitted palpation (page 83), vis- 
ceral sensitiveness is easily demonstrated. By aid of the 
vertebral reflexes (page 7), visceral pain may be accentuated 
or inhibited and the same holds good for segmental analgesia 
of the viscera (page 376). 

The local area of tenderness of visceral origin does shift 
when the vertebral reflexes are employed (Fig. 85). 

2. Hyperalgesia. — Cutaneous hyperalgesia consecu- 
tive to visceral disease has already been discussed (page 58). 
Hj-peralgesia of other structures, notably the muscles, is 
equally common. Pressure, to elicit muscular hyperalgesia 
is faulty, for the reason that one cannot exclude cutaneous 
hyperalgesia. Here, one may make passive movements, or 
the muscular tenderness may be evoked by active move- 
ments of the muscles by the patient. When the muscular 
hyperalgesia is associated with spasm, mistakes in diagnosis 
are not infrequent (page 191). 

•Lennander, conwoded thai the parietal periloneum is intensely sensitive to 
puin, but tiot to ptrssute, heat, or cold and that painful abdominal sensations uc 
transmitted by the phratac, lower ax intettostaK lumbaf and sacral nerves (which 
innervate the parietal peritoneum). The viscera! periioneum and a 
organs (innervated by vagus or jiympathetic) , are not sensitii-c to pain. 

416 



Muscular Spasms 

3. Muscular Spasms.* — The term, viscero-tnotor reflex 
has been applied to the spasm of a muscle in consequence of 
visceral disease. This reflex is commonly observed in affec- 
tions of the abdominal viscera (hardness of the abdominal 
muscles and tenderness which are accentuated by palpation). 
Muscular spasm as a peripheral symptom of visceral disease, 
may be manifested by clonic or tonic contraction and involve- 
ment of a part or the whole of a muscle. When the part of 
a muscle is involved, it may be mistaken for a tumor (page 
191). In some instances, the viscero-motor reflex in question 
is only recognized by increased resistance on palpation. 

Muscular spasms may persist during deep narcosis and 
as a rule, they yield last of all the muscles during anesthesia. 

Dr. C. A. Reed 7°, based on the observations of 
Nothnagel and Lennander, who insist that visceral pain 
is only a phenomenon of muscular hyperalgesia, seeks 
by subduing the latter to relieve visceral pain. Many 
post-operative pains following operations on the uterus 
and adnexa have been subdued (even though morphin 
failed), by deep muscular injections of the following 
solution into the hyperalgetic areas: 

I^ gm. or c.c 

Morphin hydrochlorid o|oz 

Novocain 0(04 

I 

Scopolamin o|ooi5 

Normal salt solution 1 1 

"This represents a single dose which, before adminis- 
tration, is further diluted with physiologic salt solution 
to permit of its distribution by numerous deep punctures 
with an ordinary hypodermatic needle into the hyperal- 
getic areas. 

2. For analgesia, after thoroughly cleansing the 
integument, all of the mixture is injected into the muscular 

417 



layer, several punctures being employed and care being 
taken to make them at points that approximately de6ne 
the circumference of the hyperalgetic area. The anal- 
getic effects will be realized within from five to ten 
minutes, and in consequence of ihc presence of the 
scopolamin, will be continued often from six to eight 
hours, while in so me 'in stances they will be permanent. 
3. For local anesthesia, the same solution is used in 
the same way, with the exception that it is discharged into 
the subcutaneous connective tissue at points that approxi- 
mately define the circumference of the area that it is 
desired lo anesthetize. The sensibility will disappear ii 
from five to eight minutes and will remain absent for 
a period varying from an hour to three hours," 



Reed argues that, if an algetic impulse can be telegraphed 
from viscus to muscle, an analgetic impulse can be tra 
mitted from muscle to viscus and thus pain may be c<h 
trolled. It is true that we know little of autonomic phenoifl 
ena and are not sure of that but it is reasonable to assume 
that the analgesic formula before mentioned owes its 
efficacy to its action on the sensory nerves of the muscle. 

It is known that an inflamed joint may be absolutd 
fixed in consequence of powerful contractions of the si£l 
rounding musculature. This condition may suggest a fals^ 
ankylosis and insomuch as the muscular spasm may persist 
even during narcosis, I would suggest the use of Reed's 
formula for releasing the spasm and thus aiding diagno! 

The author recalls circumscribed spasms of the sten 
mastoid muscle, which were mistaken for tumors and wh 
were dispersed by a few applications of the Faradic current. 
Mitchell reported a phantom iumor in the left pectoral 
region. 

Despite the irrelevancy of the interpolation, I wish to 

direct attention to circumscribed tonic spasms of the viscera 

418 



false 

?rslsl 

2ed's 
inosafl 
temS 
whici^ 



Muscular Spasms 

musculature. It is known that phantom tumors of the 
abdomen may be caused either by a contraction of the 
abdominal muscles or meteorism, and when such tumors 
occupy the lower abdomen, they simulate pregnancy {pseu- 
docyesis). Anesthesia may be necessary to cause their 
disappearance. To my knowledge, no reference has been 
made to circumscribed tumors of the uterus mistaken for 
fibroids and often due, as I believe, to subinvolution of the 
uterus. These pseudo-fibromata may be dispersed by elici- 
tation of the uterus reflex, (page 358). 

Dr. M. TumbuU reports the following case: 

"Patient suffers from menorrhagia and profuse metrorr- 
hagia. She is very pale, emaciated and growing pro- 
gressively weaker. Examination of the blood shows a 
profound anemia. Has been advised by several promi- 
nent gynecologists to have a myomectomy or a hysterec- 
tomy performed. All concurred in the diagnosis of an 
interstitial fibroid. Uterus is enlarged and sl fibroma? is 
distinctly palpable. Treatment consisted of eliciting the 
uterus reflex by application of the interrupted sinusoidal 
current to either side of the second lumbar spine every day 
for a period of three minutes. At the first treatment, one 
could observe contractions of the uterus through the 
speculum and the expulsion of clots of blood from the 
uterus. After about three weeks treatment, patient 
was practically cured and has continued so up to the 
present time of writing. Examination shows a normal 
uterus and the supposititious fibroid can no longer be 
palpated. The patient has been cured of a chronic 
constipation." 

{Comment by the autJwr, — The patient suffered from 
atonic constipation (page 328), and the treatment directed 
toward elicitation of the uterus reflex was equally appli- 
cable in this form of constipation. Electricity (Galvan- 
ism) has been credited with a selective effect (electro- 
chemic) on fibroids. It is probable that the action is due 

419 



to dispersion of irregular contractions of the uterine 
musculature). 

Abnormal Positions of the Uterus, caused by relaxed 
ligaments, may be improved and cured by eliciting the 
uterus reflex. Some of the ligaments contain non-stripi-d 
muscular fibers, whereas the round ligaments consist essen- 
tially of muscular tissue, prolonged from the uterus. 

Segmental Psychrotheeapy (page 375) is likewise of 
diagnostic value assuming that one is unable to palpate 
the abdominal viscera owing to rigidity of the musde. 
Reference to the table on page 33, shows the segmental 
origin of innervation and Fig. 10, the spines corresponding to 
these segments. If the spines are thoroughly frozen, palpa- 
tion is facilitated. I recall a case where taxis was employed 
without result to reduce an inguinal hernia but when freezing 
was used in the manner indicated, reduction was effected. 
In another patient, reduction was effected by refrigeratin] 
the hernia. 

MusctTiAR Rigidity in Thoracic Disease. — In 
acic affections, notably, pleurisy, pericarditis and pneumoi 
the pain may be reflected from the chest to the abdomen. 
The abdominal symptoms are often so fulminant in char- 
acter as to suggest appendicitis, peritonitis or perforation, 
and thoracic symptoms are absent or may be overlooked. 
The abdominal signs consist of tenderness and rigidity 
the muscles, abdominal pains and symptoms of colla] 
Diagnosis can usually but not always be established by 
absence of tenderness over the subjectively painful abdo- 
minal region and by a careful exploration of the chest. In 
differentiation, the use of chloroform as suggested on 
413, may be used. 

Pottenger" and Wolff-Eisner" direct attention to musci 
rigidity in thoracic disease. The latter regards lig^t toi 
420 



crating 

1 thofl 

monh^ 
nen. 
har- 
lion, 
ked. 

4 



Rigidity of the Spinal Muscles 

palpation as valuable in the recognition of pulmonary 
aflfections. Pottenger, however, is entitled to the greater 
credit for having elucidated this sign. He describes two signs : 

1. Muscle rigidity, which may be defined as a feeling 
of resistance noted on palpating the muscles which 
overlie inflammatory conditions affecdng the pulmonary 
parenchyma or pleura due to acute muscle spasm when 
the inflammation is acute and pathological change in the 
muscles when the inflammation is chronic. 

2. A feeling of different degrees of resistence noted 
over organs or parts of organs of different density on 
"light touch palpation." 

The two signs are clearly distinct. Muscle rigidity 
is confined to the muscles alone, while the difference in 
resistance found on light touch palpation applies to the 
density of tissues as found not only in the muscles, but the 
deeper organs as well, and may be used in outlining either 
normal organs or areas of disease where such disease pro- 
duces change in density of any of the tissues which we 
are able to palpate. 

Spasm of the Esophagus, notably its lower end, asso- 
ciated with cardiospasm, is not infrequently of reflex origin 
and due to hypertonicity of the vagus (page 452). 

Rigidity of the Spinal Muscles. — This subject has 
already been discussed on page 46 ei seq. There are, however, 
conditions remote from the site of the spasm which arc 
related to the latter and interpreted by the patient as back- 
ache. Such conditions embrace many aflfections of the 
lower extremities, specified as rheumatic or neuralgic and 
which owe their origin to disabilities of the feet. The latter, 
as offending factors are frequently ignored because the reflex 
backache is so far removed from the foot. Pains, specified 
as sciatica are likewise caused by some pedal infirmity. 
The most frequent condition represented by the latter is the 

421 



Secretory Reflexes 

vigorous rubbing of the infiltrations causes them to swell with accentua- 
tion of the pains. 

In addition to the treatment suggested on page 90, fihrolysin (page 
io8)y may be used by injection into the gluteal muscles. If the treat- 
ment is efiFective, the infiltrations and pain begin to disappear after 
two or three injections. 

The local application of salicylates is often of service. An ointment 
composed of two drachms of oil of wintergreen in an ounce of lanolin 
may be used, or more costly preparations, known as mesotan and 
anesthoL 

In intractable cases of fibrositis, inject into each infiltration a few 
drops of alcohol (85 per cent). Repetition of the injection may be 
indicated. Disinfection prior to injection may be achieved by painting 
the skin with iodin-tincture. 

Quinin and urea hydrochlorid (soluble i in about i of water), may 
be used as an injection (i per cent, solution). It acts as a local anes- 
thetic (also hemostatic), and the effects last from four to seven hours. 

In the author's experience, the most effective means of dispersing 
the indurations is by diathermy (page 404). The electrodes are applied 
directly over the infiltrations. 

I have frequently found very circumscribed muscular contractions 
(suggesting myistides), associated with neuralgia of the spinal 
nerves. Freezing at the vertebral exits of the affected nerves causes 
an immediate disappearance of the muscular contractions. 

4. Secretory Reflexes. — The reflex center for the 
salivary secretion is located in the medulla oblongata in 
juxtaposition to the origin of the 9th and loth cranial nerves. 
The latter may be stimulated reflexly in visceral diseases, 
notably in angina pectoris. The same reflex effects are 
noted with the secretion of urine. Thus, one notes the fre- 
quent micturition in appendicitis and the excretion of large 
quantities of urine after attacks of visceral pain. In a num- 
ber of instances, the secretory reflexes are mediated through 
the aflFerent fibers of the vagus. 

5. Vasomotor Reflexes.* — These reflexes are noted 

*Vide page 272. 

423 



Spondyloth e r a p y 

in individuals in whom there is a maladjustment of the cir- 
culatory relations; "a tempermental condition of aberrant 
motility of the vasomotor system," which is comprehen- 
sively designated by Cohen'* as, vasomotor ataxia. The 
symptoms of the latter may be : i . Constrictive ; blanching 
or cyanosis of the skin according to whether the venous or 
arterial system is predominantly aflFected. 2. Dilative or 
hyperemic; edema, flushing or cyanosis of the skin. 3. 
Mixed ; the most conmion form, in which dilatation and con- 
striction alternate, and there is cutaneous cyanosis, mottling, 
blanching and edema. The foregoing phenomena are not 
confined essentially to the skin but have also been observed 
in the eye-grounds and throat. 

For a description of the visceral angioneuroseSy the reader 
is referred to the original conmiunication of Solomon Solis 
Cohen'*. 

The vasomotor temperament, if one may be permitted to so call it, 
may be recognized by the following signs: 

Skin. — Marbled or mottled skin, intensified by cold and diminished 
by heat. The cutaneous signs may be limited to a definite region of 
the body. The hands may assume almost any color but usually the 
latter runs out upon raising the limb and upon resumption of the 
natural position, it becomes pink and then passes into purple and blue 
tints. Spastic blanching is seen in the so-called dead finger. Alter- 
nations of blanching and congestion yield the "tattooed" appearance 
and blue, red and white stripes. Pigmentation of the skin, maculated 
or diffused, and transient or permanent, is observed in one-third of 
the cases. Leucoderma is also observed. Perspiration may either 
be excessive, scanty or absent. Skin-lesions like urticaria, erythema 
and eczema, are transient and recurrent. When the hands or feet 
are immersed in hot or cold water, the responses correspond to the 
norm, although exaggerated. 

Naii s. — In nearly ever>' case there is a deep red terminal line — a 
loi^p of dilated capillaries. 

£yks. — Widening of the commissure, tremulousness of the lids 

424 



Vasomotor Reactions 

^pon light closure, dilated pupils, pain in the eyes, drooping of the 

'^ds, distention or contraction (less common) of the retinal vessels. 

Among other symptoms are: Enlargement of the thyroid gland, 

^xiregularity of the heart and tremor of the muscles in some part of the 

t^xly. 

Vasomotor Reactions. — Insufficiency of the vasomotor 
apparatus may be present in one region of the body and 
absent in another. I have essayed to elaborate a few prac- 
tical reactions which are of great value in diagnosis and 
treatment. They refer specially to the head, respiratory 
apparatus and the splanchnic circulation. Only the latter 
will receive present consideration, reference to the former 
is made on page 614. 

Course of the Vasomotor Nerves. — The relation of 
the vasomotor nerves to the spinous processes is discussed 
on page 278, but Fig. 102, from Howell, will give one a more 
comprehensive idea respecting the course of the autonomic 
(sympathetic) fibers. 

From the vasomotor center, some of the fibers pass 
directly through some of the cranial nerves to their area of 
distribution, whereas the others, descend in the spinal cord 
where they enter into connection with the subordinate vaso- 
motor centers in the cord and then leave the latter, through 
the anterior roots of the spinal nerves or pass into the sym- 
pathetic through the rami communicantes, from which point 
they attain the blood-vessels to which they are distributed. 
The following table, by Langley, illustrates the probable 
relations of the spinal roots to the ganglia of the sympathetic 
system in man, according to which the chief outflow of 
S)mipathetic fibers occurs between the first thoracic and 
second lumbar roots. 



425 



Spondjlot h e r a p y 




Ganglia of the Sympathetic System 



GANGLIA OF THE SYMPATHETIC SYSTEM. 



SPINAL-ROOT. 


CERVICAL. 


THORACIC. 


LUMBAR. 


SACRAL. 


I 


Sup. cerv. 
Sup. cerv. 
Sup. cerv. 
Sup. and inf. 
cerv 








II 








III 








IV 








V 


Sup. and inf. 

cerv 

Sup. (?) and 

inf. cerv 

Inf. cerv 


1,2 

I, 2, 3» 4, 5 

I, 2, 3, 4, 5, 6, 7, 8, 9 

? 5*6,7.8,9, lo, II, 12 
? 3,9, lo, II, 12 

II, 12 
12 






VI 






ThoracicVII 






VIII 






IX 




1,2 

I. 2. 3 
1,2,3,4 
I. 2, "i, 4., «; 




X 






XI 






XII 




I 


I 






? 2,3,4,5 i»2,3 

? ^, 4, S I- 2. 1. A. C 


Lumbar II 












c* ^» o 


1 1 yjl -r» »/ 



The ganglia of the sympathetic nervous system are as 
follows: Cervical portion ^ 3, Dorsal, 12, Lumbar ^ 4, and 
Sacral, 4 or 5 pairs of ganglia. 

The cervical sympathetic, which supplies the majority 
of the blood-vessels of the head, obtains its fibers from the 
first to the seventh thoracic roots, all of which terminate in 
the superior cervical ganglion which is located opposite the 
second and third cervical vertebrae. 

The upper extremities, are supplied by vasomotor nerves 
which terminate in the first thoracic ganglion. 

The vasomotor nerves of the lower extremities pass 
through the nerves of the lumbar and sacral plexuses into the 
sympathetic. 

Test for the Splanchnic Circulation. — Recapitulat- 
ing certain facts concerning splanchnic neurasthenia (pages 
252, 345) we note that it is a condition dependent on intra- 
abdominal venous congestion superinduced by insufficiency 
of the splanchnic vasomotor mechanism, and that the neur- 

427 



S p, n d y I t h e r a p y 

asthenic symptoms resulting therefrom may be corrected by 
by relief of the congestion, and by maneuvers which will 
increase the efficiency of the liver as an organ of defense. 

Toning the splanchnic vasomotor mechanism is the most 
potential of all methods in the treatment of splanchnic 
neurasthenia. 

It has already been observed on page 346, that when one 
presses the abdomen, or when the sinusoidal current is 
applied to the abdomen, the blood is driven from the intra- 
abdominal veins back into the heart. The latter action is 
chiefly due to the elicitation of the liver reflex (page 331), 
which results in a decided reduction in the volume of the 
liver. Insomuch as it has been estimated that the latter 
organ contains blood equivalent to one-fourth the amount 
of blood contained in the body, it is not difficult to concei\'e 
that, by contraction of the liver alone, considerable blood 
may be expressed from the splanchnic circulation. 

However, the author finds that it is now possible to in- 
fluence the latter circulation by direct stimulation of the 
splanchnic nerves which control the blood-vessels of the 
abdominal organs. 

True, digitalin or strophanthin, alone or in combination, 
quickly relieve abdominal congestion. They are endowed 
with the property of constricting the splanchnic vessels alone, 
w^hereas digitoxin constricts all the blood-vessels. 

However, with pharmaco-therapy only temporary results 
are achieved, and the latter should be superseded whenever 
possible by physio-therapy. 

Before describing the physio- therapeutic method of the 
author, it is nccessar}' to advert succinctly tO the splanchnic 
circulation. 

The latter properly comprises the arterial and venous 

428 



Sj^lanchnic Circulati 



n 



^^I>ply to the abdominal organs and is known as the splanch- 
area. The largest vascular areas in the body are: 

1 . The splanchnic area ; 

2. The brain; 

3. The muscles; 

4. The skin. 

The splanchnic area is large enough to contain almost 
the entire volume of blood of the body. 

If the portal vein is tied, practically the entire blood- 
volimie of the body will accumulate in the intestinal and 
hepatic blood-vessels and, in this way, an animal may be 
bled into its own veins. 

There is an incongruity in an animal like man built on 
the longitudinal plan. The erect posture of man causes the 
blood to gravitate into the intra-abdominal veins. 

The effect of gravity on the circulation is important. 
The chief effect of gravity is that the veins become filled 
with blood in the dependent parts. If an animal is held with 
its legs hanging down, the amount of blood going to the 
heart is reduced and the blood-pressure in the arteries is 
consequently diminished. This hydrostatic effect of gravity, 
however, is overcome in the norm by constriction of the ves- 
sels of the splanchnic area and by augmented vigor of the 
respiratory apparatus. 

If a "hutch" rabbit is suspended by the ears with its legs 
hanging down, it soon passes into unconsciousness and will, 
if left in that position, die in about half an hour. What 
occurs? The blood leaving the brain accumulates in the 
abdomen of the animal but the deficient tone of its splanchnic 
vasomotor mechanism is unable to overcome the evil effects 
of gravity. 

If the animal, however, is placed in a horizontal posture 

429 



Spondylo t h e r a p y 

or. if while still su^iended, the abdomen is squeezed or 
bandaged, consciousiess is soon restored. 

A wild rabbit, owing to its eflGident splanchnic vasomotor 
mechanisnu suJSers no inoMivenience when held in a vertical 



The Splaxchnic NER^'ES, are the vasomotor nerves of 
the abdominal blood-vessels and control the largest vascular 
area in the bodv. 

If the splanchnic nerves are stimulated, the blood-vessels 
contract, but when the nerves are cut, the vessels dilate. 

In the latter case, a large amount of blood accumulates 
in the abdominal vessels restdting in an anemia of the other 
parts of the body which may be so great (brain-anemia) as 
to cause death. 

We shall presently learn that the physician can by simple 
methods either increase or diminish the tone of the splanch- 
nic ner\'es and, in this respect, he can achieve results tanta- 
mount to the vivisectional experimentalist. 

The splanchnic nerves are composed of fibers issuing 
from the spinal cord in the 5th to the 12th dorsal nerves 
inclusive. The dorsal nerves in question correspond to the 
spines of the 2nd to the 8th dorsal vertebrae, inclusive. 

If the spines in question are sinusoidalized, or better 
still, struck in succession by means of a plexor and plexi- 
meter, the cardio-splanchnic phenomenon (page 346) is at 
once brought into evidence. In other words, the blood is 
expressed from the abdominal vessels to the right heart. 
The phenomenon in question is of short duration, hence one 
must not delay the percussion. 

If, in the norm, an individual assumes the recumbent 
posture for several minutes and is then requested to stand 
erect, and the physician at once proceeds to percuss the 

430 



The Splanchnic Nerves 

lower part of the abdomen, he will elicit two areas of dull- 
ness as shown in Fig. 103. 

The latter areas are usually of short duration and may 
be dissipated at once by a series of deep breaths or by 
striking the 2d to the 8th dorsal vertebral spines. 

What reasons have we for assuming that the dull areas 
in question are caused by the accumulation of blood in the 
abdominal blood-vessels? 

1. The areas of dullness correspond to the largest 
abdominal vessels. 

2. They are at once dissipated by deep breathing which 
facilitates the return of blood from the abdominal vessels to 
the heart and by striking or sinusoidalizing the spines of the 
2d to the 8th dorsal vertebrae. The latter methods stimu- 
late the splanchnic nerves and by thus constricting the 
vessels of the abdomen send the blood to the heart. Thus 
it is, that by the execution of the methods in question, the 
cardio-splanchnic phenomenon is brought into evidence. 

3. If a large vacuum cup is applied to the abdomen at 
a point just above the navel, and the cup is exhausted, two 
areas of dullness corresponding to Fig. 103, appear. 

4. If, in a given individual, the dull areas corresponding 
to Fig. 103, are elicited by a change from the recumbent to the 
vertical position, such areas can no longer be demonstrated 
by change of position if the vertebral spines corresponding 
to the origin of the splanchnic nerves are previously sinu- 
soidalized or concussed. By the latter method, we have 
at least temporarily, augmented the tone of the splanchnic 
vasomotor mechanism, thus inhibiting the gravitation of 
blood to the abdominal vessels in sufficient amount to elicit 
dullness. 

5. The dull areas may be evoked (although absent) in 
the erect posture, by sinusoidalization or concussion of the 

431 



S p 



d 



I 



a p y 



four lower dorsal spines (9th, loth, nth and 12th donal 
vertebrae). 

The author has determined empirically that the spines 
in question correspond to segments in the spinal cord wWch, 
when stimulated, will diminish the tone of the splanchnic 
nerves, thus permiting a large quantity of blood to gravital 
into the patulous abdominal vessels. 

6. In splanchnic neurasthenics, the patches of dullnt 
are not isolated as in the norm but the dullness is dil 
and occupies the entire lower abdomen (Fig.104). With 
betterment of the splanchnic neurasthenic there is a coi 
ponding diminution of the dullness on percussion, 
dullness in such patients is always more diffused and pi 
nounced when the symptoms of the patient are accentuati 
and it is even possible to elicit many of their sensations 
(vertigo, sinking sensations, lack of energy, etc.) or aggra- 
vate them, by concussion or sinusoidalization of the four 
lower dorsal spines which, as we have shown, practicall] 
paralyze the splanchnic nerves, thus causing an increi 
quantity of blood to accumulate in the abdominal vessels 

The author, based on an examination of hundreds of 
cases with reference to the vigor of the splanchnic vaso- 
motor mechanism submits the following classification: 

1. Patients in whom no dullness in the lower abdomen 
can be elicited when a change is made from the recumbent 
to the erect posture; a condition which demonstrates 
ideal vaso-motor mechanism. 

2. Patients in whom a dullness of short duration (1; 
ing about one minute), is elicited (Fig. 103) on change 
position; a condition representing an average vaso-moti 
mechanism. 

*Tbc author suggests to the invcstiga-toT thai the dullness of inlra-sbdoininiil a 
gestion be utilized as a. gauge in detcrtniiung the action of drugs on the spbnc 



ase^H 
els.« 



The Splanchnic N e r 'v e s 

3. Patients in whom the dullness is JilTused {Fig. 104) 
and persistent (longer than three minutes), after change 
from the recumbent to the erect position; a condition repre- 
senting an ene^^■atcd mechanism. 




;. loj. — Patches of dullness in the Fig. 104. — Diffused area of dullness 

norm, when Ihc erect is substituted for in insuftidency of the splanchnic vaso- 

thc recumbent posture; pcrcussional motor mechanism. Compare with the 

f vidence of the gtavitstion of blood into normal areas of dullness in Fig. 103. 
ihe splanchnic vessels hy ihe atlitudinal 
change in question. 

4. Patients in whom the dullness Is diffused and per- 
sistent in the erect posture without having previously adopted 
the recumbent attitude. Here, we are confronted with the 
most accentuated types of splanchnic neurasthenia. 

From what has preceded it will be evident that one must 
not base inferences on false premises. One must assure 
himself that dullness of the lower abdomen is really depend- 
ent on intra-abdominal congestion by execution of the tests 
already cited. Thus, there will be an augmentation of the 
dullness if the four lower dorsal spines are concussed or, 
inversely, the dullness will be dissipated by deep breathing 



S p n d y I t h e r a p y 

(in non-aggravated types of congestion) or by concussion 
of the upper dorsal spines (2d to the 8th). 

In the Treatment of splanchnic neurasthenia, two 
methods are available, viz.: 

1. Concussion. 

2. Sinusoidalization. 

Concussion is more efficient than sinusoidalization. Con- 
cussion is a mechanic stimulus and, when it is of short dura- 
tion, it augments the excitability of the nerves, but when 
prolonged, the excitability is diminished or abolished. It 
is evident t;hen that, in the application of a stance of con- 
cussion, the treatment must be interruoted from time to 
time. 

Mechanic stimuli are only eflfective when they are applied 
with sufficient rapidity to produce a change in the form of 

the nerve-particles. 

In the therapeutic elicitation of the splanchnic reflex of 
vaso-constriction, the only kind of vibratory apparatus which 
is effective is one giving a Percussion Stroke. The con- 
cussion is applied directly to the spinous processes in suc- 
cession. 

The duration of each daily stance should not be less than 
15 minutes, but treatment must be interrupted. 

Sinusoidalization may likewise be used for exciting 
the splanchnic reflex of vaso-constriction. The rapid sin- 
usoidal current is employed for this object. 

A large electrode is placed over the sacrum, whereas a 
small interrupting electrode (which permits one to close and 
open the circuit) is placed in succession over the indicated 
spinous processes. 

The daily stances must be at least of 15 minutes duration, 
but interrupted. 

434 



The Splanchnic Nerves 



In concluding this subject, the author wishes to direct 
attention to the vertebral reflexes in diminishing thenrolume 
of the liver which, in splanchnic neurasthenia is invariably 
enlarged. 

Our conventional conception of the liver is that of an 
organ which is hard and unyielding. 

In reality, however, the organ in question is like a sponge ; 
it swells with augmenting, and diminishes in volume with 
decreasing pressure. 

Concussion of specific vertebral spinous processes con- 
tracts the liver for the following reasons: 

1. Concussion of the 7th cervical spine acts on the 
general vaso-motor apparatus. 

2. Concussion of the first three lumbar spines acts by 
eliciting the liver reflex (page 331) of contraction. 

3. Concussion of the 2d to the 8th dorsal spines, in- 
clusive, acts by constriction of the splanchnic blood-vessels. 

In a number of measurements of the liver made in the 
parasternal line, the author obtained the following results: 

1. Size of liver by percussion before concussion, 12.5 cm. 

2. Size of liver after concussion of 7th cervical spine, 
II cm. 

3. Size of liver after concussion of ist 3 lumbar spines, 
8 cm. 

4. Size of liver after concussion of 2d to 8th dorsal 
spines, 6 cm. 

It is evident, according to the foregoing measurements, 
that, after elicitation of the splanchnic reflex of vaso-con- 
striction (4), the greatest reduction in the volume of the 
liver is obtained.* 



♦The essential facts of this subject have been excerpted from the 4th edition of the 
author's work. Splanchnic Neurasthenia, E. B. Treat & Co., New York. 

435 



S P 



t k 



r a p J 



6. Pii/>MryroB. Reflxxes. — ^ScinB^uson of die pQo- 

TTi'irnrFiTT' '7 — r'rnni — imin if rfir r m H in \ fSm tm . ssd 
die reaa causes the appearance of "gooEc^kiii" (fsiu' 
■znxrixiij. Wben. the moscfes ■fn c tan s pSarmm) stodmi 
^j the haFr-nTrirt. cnctracL in adiiftum tn tiie gooee-skm. one 
eaperiencES a chHIj =egsatiop wfikiL e probs.bb' doe tt> vaao- 
constnctioc- 

Mackenzie'^ 'ibserves that, 'd the skm rrrwyr - dK nqjple 
i= rubfeeri T^ith 3az3eL afxee-sfciii appeal^ cTwrr tlie port 






nibteii and eiterMl* to the clavicle and to the inner adc of 
the upper arm and forearm. At the same trme the pupQ 
dilates. This phenomenon is explained br noting that the 



Paravertebral Tenderness 

is observed over these vertebrae. The results are only 
approxiioate. Subdued light must be used. Limited areas 
(rf anemia with elevation of hairs are associated with the 
goose-skin. In other instances, a faint tremor of the muscles 
may be noted. The pilo-motor reflexes are rapidly exhausted. 

7. Paravertebral Tenderness. — This subject has 
already been discussed on page 71, e/ seqtientia, and I have 
not modified my views respecting the reason for the tender- 
ness. Certainly it is not a question of congestion, insomuch 
as cupping to one side of the tender areas only accentuates 
the vertebral and peripheral areas of tenderness. We asso- 
ciate tenderness with congestion despite the fact that paiti 
is often the piteous appeal of a hungry nerve for blood. In 
several instances, when freezing, which is the sovereign 
remedy for dissipating tenderness, was ineffective, notably 
in intercostal pains, suspension of the patient (Fig. 116), caused 
the disappearance of the vertebral and peripheral points of 
tenderness. Here one assumed, and the results demon- 
strated the verity of the assumption, that the pains were 
caused by a faulty posture (Vide foot-note, page 186). 

8. Elevation of Temperature. — Rise of temperature 
consecutive to concussion has already been noted on page 
180. Recently, the author has observed the curious fact 
that pressure exerted and maintained for about two minutes 
with an instrument (Fig. 1 1 2) at the vertebral exits of any of 
the spinal nerves, will also elevate the temperature from .6 to 
1.6® F. The mechanic irritation thus evoked, is equivalent 
to a pathologic irritation caused by visceral disease and 
manifested by areas of vertebral tenderness. 

The fact just cited may explain the elevation of temperature in 
some conditions. The even temperature of the body is maintained by 
a thermotactic condition which adjusts the rate of heat-production 
(thermogenic factor) and heat-radiation (thermolytic factor). 

437 



Spondyloth 



e r a p y 




T\g. io6.— Representing the mechanism of visceral pain, cutaneous and 
muscular hyperalgesia (viscero-sensory reflex), the viscero-motor reflex and the 
organic reflex. A stimulus from the organ, V, by the sympathetic nerve (Sy. N.), 
to its center in the spinal cord extends to the adjacent cells of nerves, and excites 
them to activity, when the function peculiar to each nerve is exhibited. Thus the 
stimulus aflFecting the cells of a pain-nerve (SN), eventuates in the perception of 
pain which is referred by the brain to the peripheral distribution of the nerve in the 
external body-wall (Sk. M); affecting the cell of a motor nerve (MN), causes a con- 
traction of the muscle (M), supplied by the motor nerve; aflFecting the cells innervat- 
ing other viscera (as V), stimulates them to their peculiar function (contraction of 
a hollow muscular \'iscus, increased secretion of a secretory organ). If the stimulus 
is of suflicient strength, it may leave an irritable focus in the spinal cord (shaded 
arci), as shown by a persistent hyperalgesia of skin and muscle (Sk. M), and by a 
persistent contraction of the muscle (M). 

438 



Irritable Spinal Segments 

The relation of the latter factors to thermotaxis may be repre- 
sented as follows: 

Thermogenesis. 

Temperature= 

Thermolysis. 

The impulses of temperature and pain which are intimately 
associated, enter the spinal cord at the same point and pass into the 
gray matter. 

Mechanism of Peripheral Reflexes in Visceral 
Disease. — Fig. 22 (page 58), illustrates cutaneous tender- 
ness and radiation of pain in visceral disease and Fig. 106, 
from Mackenzie shows the viscero-motor and sensory 
reflexes. 

Irritable Spinal Segments. — Irritable foci in the cord 
may survive the apparent cure of a visceral disease. This 
is shown by the persistent areas of vertebral tenderness, the 
accentuation of physiologic reflexes, persistent dermatomes, 
reflex muscular contractions corresponding to the irritable 
spinal segment, and subjective sensations corresponding to 
the hypersensitive spinal segments. It is not unusual for 
patients to complain of pains or sensations in definite 
regions of the body (previously implicated in visceral disease) 
under emotional influences. 

PsEUDO- Visceral Diseases. — It is impossible to exaggerate the 
importance of this subject which has already been discussed in Chapter 
VI. Neuralgia of the spinal nerves is the greatest simulator of visceral 
diseases, 

A spinal segment is a unit possessed of motor, sensory, vaso-motor, 
trophic and reflex functions, with regard to the peripheral distribution 
of the roots of the nerves which emerge from and enter it. 

The following case of pseudo phthisis is cited to illustrate the im- 
portance of this subject: A young man was sent to California by his 
physicians in consequence of a painful and incessant cough. Paroxys- 
mal pains located in the ri^ht upper chest were severe. The patient 
had lost alx;ut 20 pounds in weight. The ausoiltatory evidence on 

439 



Reflexes of the Cranial Nerves 

commonly misinterpreted. It is now possible to demon- 
strate objectively this overflow of cranial-nerve irritation, 
and thus eliminate many inchoate data foimded on sub- 
jective symptomatology. 

The Eye. — Hansell correctly observes: "We have not 
yet advanced to that stage when we study diseases of the 
body in relation to ocular defects, and fail to consider 
diseases of the eye in relation to general diseases," and 
Helmholtz contended that nature seems to have packed the 
eye with mistakes, as if with the avowed purpose of destroy- 
ing any possible foundation for the theory that organs are 
adapted to their environment. 

An ocular defect is one of the most common peripheral 
irritants in the creation of reflexes, and well-fitting glasses, 
have frequently achieved the marvelous task of translating a 
pessimist into an optimist, so essential is correct vision for 
our condition of well-being. 

The following nerves enter into the innervation of the 
eye and its appendages: i. Optic nerve; 2. Motor oculi; 
3. Trochlear (pathetic); 4. Trigeminus (trifacial); 5. 
Abducens; 6. Facial; 7. Branches from the carotid and 
cavernous plexuses of the sympathetic system. The nerves 
just cited anastomose with the vagus (pneumo-gastric) and the 
upper cervical nerves. 

Fig. 108 (from O'Malley^), represents a diagram of the 
ocular nervous system. 

The motor oculi or third cranial nerve has three sets of 
fibers. I . One set supplies all the external ocular muscles 
(excepting the external rectus and superior oblique) and the 
levator of the upper lid. 2. A set to the pupillary sphincters. 
3. A set to the ciliary muscle (muscle of accommodation). 
It is impossible even in the norm to conceive the eye as 
an organ functionating independently of the other organs. 

441 




there is a relaxation of tlie refractive apparatus and it is ' 
passive (except the retina) in visualization. In normal 
accommodation, which is associated with neither fatigue 
nor irritation, objects near the eye are focused clearly upoa J 
the retina by involuntary action of the ciliary muscle which I 
curves the anterior surface of the lens. 



Reflexes of the C ranial Nerv es 

In errors of refraction, the brunt of the burden is borne 
by the ciliary muscle and nerves, thus conducing to their 
exhaustion and irritation. 

Among the reflex S3rmptoms of refractive disturbances 
are headaches and functional derangements of the heart and 
stomach. Zimmerman, in a study of 2,000 eye-cases, cal- 
culated that over 71 per cent suffered from headache and 
de Schweinitz, contends that, 60 per cent of all ocular 
headaches are caused by astigmatism. 

I proceeded to study reflex symptoms from ocular anom- 
alies by straining the accommodation of normal subjects and 
by wearing glasses which caused asthenopia (eye-strain due 
to fatigue of the ciliary or extraocular muscles). After this 
manner, one could note the development of objective S3nnp- 
toms. 

Even in the norm, if one eye of the patient is covered, and 
the other eye is forced to view an object under strain for a 
number of seconds, the primary manifestation is tremor or 
spasm of the cervical muscles on one or the other side (Vide, 
page 124). Later, one or several points of vertebral tender- 
ness develop and areas of sensitiveness may be elicited in 
the course of the cervico-occipital nerves (midway between 
the mastoid process and the spine, the stemomastoid and 
the trapezius, and above the parietal eminence). 

While the eye is still under strain, the tonus of the vagus 
is augmented ; the pulse is partially or completely inhibited 
(best seen in sphygmograms), there is a descent of the lower 
lung-border, recession of the heart (heart reflex) and the 
stomach can be percussed. If the eye-strain is continued, 
the stomach alters its position as in the act of vomiting. In 
other words, the chief reflex visceral phenomena are mediated 
by the vagus. Mere pressure on the eye-ball suffices to pro- 

443 



Spondyloth e r a p y 

voke the vagal reflexes but not the reflex sensory disturbances 
of the cervico-occipital nerves. 

In diagnosis, each eye may be tested separately. The 
signs observed in the norm when accommodation is strained 
are accentuated and persistent in asthenopia. 

By this method of testing, the sjrmptoms from which the 
patient suffers may be reproduced and, by inhibiting the 
ocular reflexes (page 443), the diagnosis may be clinched. 

Reflex disturbances from the ear and nose are described 
in the following chapter. 



444 



T 71 u s f t h e Vagus 



CHAPTER XIII. 

TONUS OF THE VAGUS AND PHARMACOLOGY OF THE 

REFLEXES* 

TONUS OF THE VAGUS — ANATOMY OF THE VAGUS — ^PHYSIOLOGY AND 
CLINICAL PATHOLOGY OF THE VAGUS — DIAGNOSIS OF VAGUS- 
TONUS — VAGUS-TONE AND THE SENSE ORGANS — ^PSYCHOVAGUS- 
TONE — METHODS FOR INCREASING AND DECREASING VAGUS- 
TONE — ^THERAPEUTIC RESULTS — DISEASES CAUSED BY VAGUS — 
HYPERTONIA AND VAGUS — HYPOTONIA — PHYLOGENETIC DISEASES 
— VAGAL HYPERESTHESIA— CLINICAL PHARMACOLOGY. 

TN this chapter the author will endeavor to show, how by 
mere pressure of certain vertebral areas, one may tem- 
porarily or permanently inhibit the phenomena of a number 
of diseases in consequence of the elicitation of definite 
vertebral reflexes. 

The citation of simple maneuvers to attain puissant 
results does not impugn scientific medicine, on the contrary, 
it demonstrates the paths of least resistance in combating 
reflex phenomena. 

J. Madison Taylor**, in commenting on the hand as a 
therapeutic agent, shows that, "often by clumsy, empirical 
methods great things are, and greater things can be, thereby 
done." He proceeds to say, "The body is like a piano or 
harp, to be played upon at will." He relates how by 

♦This is regarded by the author as one of the most important chapters in the book, 
but demands careful study. It shows that there are many diseases regarded as 
distinct affections which are merely symptomatic of a fundamental condition, 
viz. : hypotonicity or hypertonicity of the vagus. Thus it is that several diseases 
grow from a common pathogenic trunk. 

445 



manual treatment his daughter was promptly cured of a 
lameness whicli had resisted the ctTorts of the best surgeons. 

Much in physiotherapy has justly been discredited, 
owing to exaggerated statements emanating from incompe- 
tent sources. Cures mean nothing to the scientist. The 
author, in the application of his methods, has never been 
influenced by empiricism alone, and the elicitation of hisg 
reflexes to combat disease may easily be demonstrated 1 
anybody reasonably skilled in ph}'sical diagnosis. 

The subject of tonus of the vagus has engaged the attei 
tlon of the author for years and it is only recently that an^ 
thing approaching the confirmation of his investigations 1: 
appeared. 

In a monograph*, which is largely hj-pothetic, emanati 
from the von Noorden clinic, an endeavor has been made to"" 
demonstrate the relation of the tone of the vagus to other 
diseases. Insomuch as there is no evidence in this mono- 
graph to recognize the tone of the vagus by its effects oa J 
the visceral reflexes, the discussion is necessarily theoretic I 

Before studying this subject, it is necessary to recapitulatB 
certain facts concerning the vagus. 

Anatomy of the vagus. — The tenth or pneumo- 
gastric nerve (nervus vagus), is the longest and most 
extensively distributed cranial nerve and contains motor 
and sensory fibers. The branches of the nen^e are 
shown in Fig. 109. 

The vagus communicates with the 9th, i 
nerves, with the sympathetic, and with the loop between 
the ist and 2nd cervical nerves. The following are the 
lerminal branches: Meningeal, auricular, pharyngeal, 
superior and inferior laryngeal, cardiac, pericardial, 
bronchial, esophageal and abdominal branches. 



Anatomy of the Vagus 




VSIOLOGY AND CLINICAL PATHOLOGY OF THE VAGLS- 

The nerve is motor, for the soft palate, pharynx, lan"ax, 
bronchial muscle, heart and abdominal organs. The nen-e 
is sensory for the pharynx, larynx, trachea, esophagus and 
probably the heart. 

When the nerve Is diminished in tonus (which will be 
described later), it produces symptoms varying in the motor 
sphere from hypotonia (page 52), to paralysis and, in the 
sensory sphere, from hyperesthesia (diminished sensibility), 
to anesthesia. 

Increased tonus of the vagus in the motor sphere is asso- 
ciated with spasms and in the sensory sphere with hyper- 
esthesia. 

The following anomalies are associated with individual 
branches of the vagus : 

1. Pharyngeal branches. — The muscles and 
mucosa of the pharynx are implicated and deglutition is 
impaired. Spasm of the pharynx is manifested by the 
"globus hystericus," in hysterical subjects and dysphagia, 
in nervous individuals. 

2. Laryngeal bkanches. — Paralysis and spasm of 
the laryngeal muscles. Spasm is not uncommon in 
children (laryngismus stridulus). Hyperesthesia and 
anesthesia of ihe laryngeal mucosa. 

3. Cardiac branches. — The motor fibers inhibit 
and control the action of the heart. In hypertonidty, 
the heart's action is retarded, whereas, in bypotonicity, 
owing to the uninfluenced accelerator action, all grades 
of heart-hurry {tachycardia) may be present. The sen- 
sory symptoms in lesions of these branches include ir- 
regularities, palpitation, and other subjective symptoms 
of cardiac neuroses. In lesions of the vagus, fatty de- 
generation of the myocardium has been observed, hence 
the nerve has a trophic function. 

The inhibitory action of the vagus on the heart is 
manifested in controlling the rhyihmicity {chronotropic 
448 



I 



Physiology of the Vagus 



Boa 



actum), irritability (balhrnotropic), conductivity {dfomo- 
tropic), contractility (inotropic),' and tonicity. 

Blood-pressure is indirectly under vagus-control. 

4. Pulmonary branches. — The motor fibers in a 
hypertonic state produce spasmodic bronchostenosis 
(page 311), and asthma, whereas, in a hypotonic con- 
dition, they conduce to dilatation of the lungs and em- 
ph3rsema. One knows that the vagus contains fibers 
which can constrict or dilate the bronchi (page 308). 
In hypertonia of the nerve, the sensitized mucosa of the 
air-passages accentuates the cough-reflex. 

5. Esophageal branches. — Spasm of the esoph- 
agus (esophagismus), cardiospasm and paralysis. Dys- 
phagia is the essential symptom in these conditions. 

6. Gastric branches. — Insomuch as the vagus is 
the motor nerve of the stomach, it is identified with the 
motor neuroses of the organ. The vagus also contains 
secretory nerves for the gastric mucosa, and is therefore 
associated with the secretory and most probably with the 
sensory neuroses of the stomach. 

Among other functions attributed to the vagus are: 
Vasoconsjtrictor fibers for the heart, stomach, intestine, 
kidneys, spleen, and possibly the lungs; vasodilator 
fibers for the coronary vessels and the lungs, inhibitory 
fibers for the cardiac sphincter of the stomach, longi- 
tudinal muscles of the small intestine and bronchial 
muscles, and secretory nerves of the pancreas. 

Another important function of this nerve is to main- 
tain the tonus of the thoracic and abdominal viscera. 

There are many problems in the physiology of this 
nerve which have not been sdved by the physiologist, 
hence the aid of the clinician must not be ignored, inso- 
much as the nature of many diseases is revealed by the 
remedies employed. 

Nervous system. — This is divided into cerebrospinal 
and sympathetic. 

The cerebrospinal system consists of the brain, spinal 

449 



S p 



d 



I 



h 



cord, cranial and spinal nerves. It supplies the 
senses and the voluntary muscles. 

The sympatketic nervous system (Fig. loi), presides 01 
the visceral movements, controls the phenomena of secretJl 
and influences the caliber of the blood-vessels. 

Anatomically, these two nervous systems are with dil 
culty differentiated, but this difficulty is surmounted by 
use of nicotin. The function of the sympathetic fibers is 
inhibited by painting them with nicotin, whereas the same 
agent is without effect on fibers of the cerebro-spinal sj-stem. 

The sympathelic systan is composed of fibers which 
according to their origin may be divided into cranial, bulbar 
and sacral (Fig. loi). 

1. Cranial DIVISION. — This is composed essentially 
of fibers which pass to the eye through the oculo-motor 

2. BiTLBAR DIVISION. — The fibers of this division 
pass through the facial and gloaso-pharyngeat nerves 
and innervate the glands and blood-vessels of the head. 
The chief nerve of this division is the vagus, which is the 
chief nerve of the viscera. 

3. Sacral division. — This innervates the struc- 
tures shown in Fig. loi. 

FiniTHER DIFFERENTIATION OF THE S'VMPATHETIC. — A] 
the ner\'e-fibers of this system which run into the gangliated 
cords of the sympalhetk (Fig. 102), are known as sjTnpathetic 
fibers, whereas the others are called aulononiic (page 41 
which represent essentially the extended vagus. 

These two sets of fibers are physiologically in antagonii 
the irritation of one set inhibiting the functions of the other 
set. Each set shows a definite pharmacologic reaction 
equivalent to their electric stimulation. 

Adrenalin acts exclusively on the s>Tnpathetic, whei 
the autonomic fibers are stimulated by pilocarpin, 
450 



leuc 

M 



onus f t h e Vagus 

The behavior of atropin is peculiar. It may inhibit 
the action of other drugs on the autonomic fibers and 
while its action is most powerful on the cranial division, it is 
practically without effect on the sacral division. 

The chromaffin system. — ^This refers to an organ or 
group of organs made up of certain cells which show a 
specific staining reaction with the salts of chromium. These 
cells have the same embryonic origin as the sympathetic 
nerves and are found with the latter in groups from the 
base of the skull to the bottom of the pelvis. 

The medullary portion of the adrenal glands contains the 
largest group of these cells from which epinephrin is derived. 

There is an intimate relation existing between the 
thyroid and pancreas and the chromaffin system. 

Tonus of the vagus. — ^What has been said on page 409, 
respecting the tone of muscles applies with equal cogency 
to the viscera. In health, the viscera are in a state of 
tonicity, i. e.j their musculature is in a more or less permanent 
although variable condition of contraction. Physiologists 
give us little information concerning the factors controlling 
visceral tonicity, although they admit that the function is 
most important in regulating the cavities of the heart and 
other organs. 

The sympathetic fibers are stimulated experimentally 
by adrenalin (sympathicotropic action), and the tonus of 
these fibers in the organism is maintained by the constant 
secretion of adrenalin and other products (epinephrin, 
suprarenalin), from the adrenal bodies. A similar internal 
secretion has not yet been demonstrated for maintaining the 
tonus of the autonomic fibers, although we know that such 
physiologic action can be exhibited by pilocarpin (vagotropic 
action). 

It has been shown that the pancreas has an inhibitor)^ 

451 



/ 



influence on the secretion of adrenalin and that after e: 
pation of the pancreas, adrenalin is increased. When 
adrenalin secretion is augmented, the reflexes of the sym- 
pathetic fibers are increased, and conversely, diminished 
when the secretion is reduced. The pharmacologic 
excitation cited, is analogous to what occurs when the 
sympathetic fibers supplying the iris are cut, viz., pupil 
contraction and dilatation of the pupil, when the autonoi 
fibers are divided. 

In the norm, when an adrenalin solution is dropped 
the eye, no dilatation of the pupil ensues, but in diabetes, 
with pancreatic involvement, such instillation causes mydri- 
asis. In diseases of the pancreas, the inhibitory influei 
of the pancreas on adrenalin secretion is checked. V 
the sympathetic and autonomic fibers are equally stimulal 
we have what is known as tonic mnervation. 

In my experimental and clinical work, I have conce! 
myself chiefly with the tonus of the vagus and cUnu 
pictures have been evolved which are identified either wil 
a diminution of vagus-tone {vagus-hypotonia), or an au| 
mentation of tone (yagus-hypertonia). Variations in vagus- 
tone may involve the entire nerve, or it may be confined to 
one or more of its individual branches {Local vagus-hypotoi 
or hypertonia). 

Humans, like animals, show variations in vagus-toi 
Thus in some aninuls, section of the vagus (vagotom; 
will produce tachycardia, whereas in other animals no su< 
action is observed. The vagus is more active in middle 
than in old age, and least active in infancy. 

In some humans, infinitesimal doses of atropin (whit 
inhibit vagus-impulses), will produce tachycardia, mydrii 
glycosuria, etc., whereas in others large doses of the 
drug produce scarcely any effects. 
452 



the 
Ua rv [ 

oia|^H 




Diagnosis of Vagus-tonus 

Diagnosis of vagus-tonus. — i. Pharmacologic meth- 
ods. 2. Paravertebral pressure. 3. Therapeutic results. 

I. Pharmacologic methods. — Insomuch as adrenalin 
acts exclusively on the sympathetic, and pilocarpin on the 
autonomic fibers, adrenalin will ameliorate symptoms 
caused by augmented vagus-tonus, whereas pilocarpin will 
increase them. 

If one concusses the first three lumbar spines to produce 
the stomach reflex of contraction (page 316), one finds that, 
after an hypodermatic injection of 8 minims of a solution of 
adrenalin chlorid, i :iooo, the stomach instead of contracting 
as in the norm, dilates (stomach reflex of dilatation). Thus, 
before concussion of the spines in question, the stomach 
retracted 2J cm., whereas after the injection, it dilated 2 cm. 

After an injection of pilocarpin, the stomach reflexes are 
accentuated. 

Thus, 

Stomach reflex of contraction before injection, 3 cm. 
" " " after " 5 cm. 

" " dOation before " 2 cm. 

" " " after " 3.8 cm. 

Atropin paralyzes the motor endings of the vagus. An 
injection of o.ooi gm. (gr. 1-60), of the latter drug will 
manifest its action within thirty minutes and disappears in 
from one to three hours. During the full physiologic action 
of the drug, the stomach reflexes are abolished. 

Atropin may thus be utilized in excluding any aug- 
mented irritability (hyperkinesis) of the vagus-endings in the 
stomach. Thus the motor neuroses of the organ (super- 
motility, peristaltic unrest, gastric crises, spasm of the 
cardia, and pylorus, etc.), must yield to an adequate dose of 
atropin. An injection of pilocarpin will, on the contrary, 
accentuate the motor neuroses. 

453 



S p n il y I 



P 3 



\ gastric ukcr will simulate many gastric diseases. 

In suspected ulcer, a drachm of salt in a glass of 
water, ingested on an empty stomach will excite an 
attack of pain. 

Hydrogen peroxid, used for the same object, causes 
a burning sensation. ■ 

Orlko/orm (8 grains), in one ounce of hot water will 
only arrest the pains of an abraded surface (ulcer). 

If the gastric pain is caused by hyperesthesia due to 
hydrochloric add, lo drops of the dilute acid ingested 
while fasting causes epigastralgia, which is relieved by 
sodium bicarbonate. 

Rinsing out the stomach with a i per cent, solution 
of glacial acetic acid closes the pylorus, and if there is a 
positive reaction of blood in the syphoned fluid, it 
speaks for a gastric in lieu of a duodenal ulcer." 

The heart reflex (page 199), is abolished by atropin and 
accentuated by pilocarpin. Thirty minutes after an injec- 
jection of pilocarpin (gr, i-io), the heart reflex measured 
4 cm., after irritating the precordial skin, whereas before 
the injection, like irritation elicited a reflex measuring 2 cm. 

In several instances when it was impossible to elicit the 
heart reflex, the latter could be demonstrated after an in- 
jection of pilocarpin. 

The majority of cases of heart-block (Adams-Stokes 
syndrome), are caused by lesions of the auriculo-ven- 
tricular bundle, but there are also neurogenic forms due 
to vagus-hypertonia. Atropin, which paralyzes the vagi, 
removes the block in the neurogenic, (pulse-rate becomes 
rapid), but not in the myogenic forms. Atropin increases 
the pulse-rate in bradycardia due to direct or reflex 
excitation of the vagus. Aconite tincture slows the heart 
by vagus-siimulalion and if it slows the pulse in tachy- 
cardia, vagus-hyp olonia is present. 

Vagus-stimulation not only slows the heart-rate, but 
creates irregularities in rhythm. If this vagus influence 
4S4 



Pharmacologic M e t h o 

is eliminated by atropin and arrhythmia disappears, the 
neurogenic nature of the irregularity is demonstrated. 

One may physiologically block a host of reflex cardiac 
anomalies by an adequate dose of atropin. Thus, a case 
of angina pectoris vasomotoria may be dted with the 
following signs: heart s3rmptoms, chest-pressure and fear 
ensuing from exposure to cold. Here, the peripheral 
vasoconstriction due to cold by increasing blood pressure 
stimulates the depressor nerve, which in turn by acting on 
the vagus causes cardiac signs. By paralyzing this 
physiologic chain with atropin, the hands may be dipped 
into ice-water without subsequent symptoms, but the 
latter reappear after the effects of atropin have evan- 
esced." 

The lung refiexe^ (P^g^ 294 et seq.), are mediated by 
vagal action. Thirty minutes after an injection of atropin 
(gr. 1-60), both lung reflexes are absolutely abolished. 

It is well known that small doses of pilocarpin are 
almost exactly antagonistic in their action to atropin, 
and this applies in all cogency to their action on the 
vagus. 

After an hypodermatic injection of pilocarpin (gr. 
I -10), one may note an exaggeration of both lung reflexes. 

Thus, before the injection of pilocarpin, the lower 
lung-border posteriorly could be made to descend (lung 
reflex of dilatation), 4 cm. after cutaneous irritation, 
whereas, after the injection, the border in question 
descended 7 cm. 



♦In a recent work by Leonard Hill {Further advances in Physiology), the following 
obscure observation is made: "Even now most medical writers ascribe the 
reflex contraction of the lung (Abrams' reflex), which follows any stimulation 
of the chest-wall to the action of the bronchial musculature. It is more prob- 
able that the retraction of the lung is due to a reflex contraction of the muscu- 
lature of the body-wall." Misconception concerning the lung reflex is due to 
the failure to recognize two distinct lung reflexes and to properly interpret 
their rationale. 

455 



The lung refiex of contraction before the injection 
lasted ^o seconds, whereas, aiter the injection, it lasted 
fully one minute. 

After an hypodermatic injection of 8 mtniins of a. 
i;iooo adrenalin chlorid solution, the following phe- 
nomenon was observed: A/tcr cutaneous irritalian, the 
lower lung border insUad of descending as in the norm 
(lung reflex of dilatation), receded Jrom 3 to 4 cm. In 
other words, cutaneous irritation elicited the lung reflex 
of contraction in lieu of the counter reflex of dilatation. 

If one accepts the prevailing opinion that, asthma 
consists essentially of a spasmodic constriction of the 
bronchioles, then an appropriate dose of atropin which 
paralyzes the bronchial musculature through its action 
on the motor endings of the vagus, must invariably 
inbibit an asthmatic paroxysm. 

Here, the action of atropin, as some assume, is not 
caused by a dilatation of the bronchi, because the action 
of the drug is to paralyze the dilator as well as the con- 
strictor fibers of the bronchial musculature. 

Atropin in sufficiently large doses is one of the most 
satisfactory drugs in asthma, and aade from its action 
in inhibiting bronchospasm, it diminishes secretion, 
reduces the sensitiveness of the mucous membranes to 
reflexes, and stimulates the respiratory center. 

Now, as a matter of fact, all asthmatic paroxysms do 
nol yield to atropin, hence one is constrained to conclude 
that bronchospasm is not the invariable concomitant of 
asthma. There may be a hyperemia of the bronchial 
alogous to urticaria, a swelling of the same 
, even an exudative bronchiolitis. 

Determining the tonus of the lung reflex of contraction 
is an important lest in differential diagnosis. In asthma 
due to a defective bronchial musculature, the lung reflex 
of contraction cannot be elicited. 

A supposed spasmodic factor in the pathology of 
pulmonary diseases must yield to atropin, and in this 
sense atropin is of diagnostic-therapeutic value. 

4Sb 



Pharmacologic Methods 

Adrenalin chlorid (in doses from 8 to 15 minims 
hypodermatically of the 1:1000 solution), is one of the 
most efficient agents in inhibiting an attack of asthma. 

The action of this drug was discovered by Kaplan 
and Bullowa, and it may truly be regarded as a specific in 
arresting many paroxysms of asthma. 

As noted by the investigations of the writer, adrenalin 
chlorid evokes the lung reflex of contraction which per- 
mits the longitudinal fibers of the bronchial muscidature 
to expel the residual air imprisoned by the spasm of the 
circular fibers.* 

It is furthermore evident that, in our employment of 
drugs in the treatment of asthma, it is irrational to com- 
bine atropin and adrenalin in the same prescription. 

The aortic reflex of contraction is controlled by vagus- 
tone. The aorta contracts in proportion as the tone of the 
vagus is increased. 

Reference to Fig. no, shows the effects of pilocarpin 
(which increases vagus-tone), on an aortic abdominal aneu- 
rysm, and although I have never found it necessary to 
employ this drug in the treatment of aneurysms, it will aid 
the physio-therapeutic methods as a synergist, should one 
encounter cases resistant to treatment. 

Atropin will inhibit the aortic reflexes. 

The effects of adrenalin on an aneurysm of the abdomi- 
nal aorta are shown in Fig. in. This drug dilates an aneu- 
rysm of the aorta. 

While it is true that the majority of vessels are con- 
stricted by adrenalin, the effect is not uniform. Even in 
the norm, dilator effects have been noted. 

The physiologic tonus of the vagus is dependent on the 
thyroid secretion, WTien the latter is diminished (hypo- 
thyroidism), symptoms of cardiac weakness may be present, 

*Videy the spasmo-paralytic hypothesis of asthma (page 308). 

457 



Spondylotherapy 

but it is usually an increased secretion (hyperth3rroidism), 
which diminishes vagus-tone. As a rule, in hypoth3rroidism, 




Fig. no. — Illustrating the effects of an h)rpodermic injection of pilocarpin 
(gr. i-io) on an aneurysm of the abdominal aorta. A, outline of aneurysm by 
percussion before injection; B and C, aortic reflexes of contraction and dilatation 
before injection; D, contraction of aneurysm by the action of pilocarpin unaided 
by the elidtation of the aortic reflex. The degree of contraction extends from 
A to D. E, the degree of contraction of the aneurysm after the use of {nkxarpin 
suded by the aortic reflex of contraction (extent of reflex from D to E). 

the use of thyroid extract by ameliorating certain s)nnptonis, 
is diagnostic. In hyperthyroidism, antithyroidin or the 
antiserum of Beebe, may improve the condition. It is well 
to know that the cardiac signs of Basedow's disease are 
accentuated by ten 5-grain doses of a reliable thyroid pre- 
paration, lodothyrin or iodin will act in the same way 
and intolerance to iodin is an early sign of hyperthyroidism. 

458 



Pharmacologic Methods 

My investigations show that, even in the norm, reduction 
in the vagus-tone may be demonstrated after a few doses of 
thyroid extract by methods described on page 469.* 




Fig. III. — Illustrating the effects of an hypodermic injection of 8 minims of 
adrenaUn chlorid (i:iooo) on an aneurysm of the abdominal aorta, i, area of 
aneurysm by percussion before the injection; 2, aortic reflex of dilatation before the 
injection; 3, area of aneurysm by percussion after the injection which persisted for 
an hour; 4, aortic reflex of dilatation after the injection. 

*In phihisist the author has found the vagus to be in a condition of hypertonicity 
as far as the pulmonary branches are concerned and he has used thyroid ex- 
tract (with poor results) in reducing such tonicity. Thus, in one patient, be- 
fore giving the extract in five grain doses thrice daily, the lower lung-border 
descended 5 cm. (after pressure on either side of the 7th cervical spine). 
After the first day, it descended only 2 cm., on the second day, i cm., and on 
the third day, .6 cm. 

459 



Spondyloth 



Inaccuracy of thyroid medication is due to variations 
in the iodin-content of the different preparations on the 
market and to the fact that the weight of the tablets is 
based on different standards. If the preparation is 
reliable, it will be shown by the progressive immobility 
of the lower lung-border after vagus- stimulation (page 
459). The latter test is so simple and reliable that the 
author suggests as a field for pharma co-clinical research, 
the action of different drugs on vagus-lone. 

Bromids induce the excitability of the motor area in I 
cerebral cortex and they also act on the motor and sensory 
columns of the cord by reducing their motor and sensory 
conductivity. They reduce all vagal reflexes and are ' 
uable in diagnosis. 

To get the effect o£ bromids, or for that matter, any 
other drugs, we must push them to saturation, until the 
border-line* of toxicity and physiologic action is reached. 
In the use of bromids we have attained our object for 
diagnostic or therapeutic purposes when the palate reSex 
is lost. The pharyngeal reflex may even be abolished in 
the norm, hence this reflex is only of value if tested prior 
to the administration of the bromids. When the period 
of intoxication with bromids is reached, there is myd- 
riasis and loss of pupillary reSex to light and accom- 
modation. Nervous dyspeptics show improved digestion 
after bromids have been used in large doses for several 
days. This therapeutic test enables us to differentiate 
gastric symptoms dependent on lesions of the viscus 
from those caused by an exhausted nervous system. 

High bhod-prenure is often maintained as a result 
of augmented tonus of the vasomotor center and is quite 
independent of vascular disease. It is essentially a ner- 
vous phenomenon and usually due to psychic stimulation 
(psychogenic hypeHensinn). Such cases do not respond 
to the author's method of concussion (page 249), but 
yield to bromids, as indicated on page 347. 

460 



Hypertensio 

Respecting hypertension^ the author finds that better 
results are achieved by concussing the region between 
the third and fourth dorsal spines, in lieu of the second 
and third dorsal spines as described on page 247, when 
the high blood-pressure is not associated with cardiac 
insufficiency. Hypertension is mediated by the vagus 
and pressure at the point indicated diminishes vagus- 
tone and augments the quantity of blood in the splanch- 
nic vessels. The latter may be demonstrated by the 
areas of dulness on the abdomen {vide Fig. 103), sequen- 
tial to pressure. Concussion of the four lower dorsal 
spines will likewise cause the areas of abdominal dulness 
(Fig. 103), but if pressure is executed synchronously at 
the 7th cervical spine (which increases vagus-tone), no 
areas of dulness can be elicited. This shows that the 
centers of the cord corresponding to the four lower dorsal 
vertebrae are subsidiary to the dominant influence of 
the vagus. 

Dr. H. C. Sawyer contributes the following report 
concerning a case of hypertension: ''Woman, 60 years 
of age, blood-pressure 210 mm., reduced to 160 mm., 
after several months treatment at a sanatorium. When 
treatment by concussion was commenced pressure was 
180 mm. Treatment by concussion thrice weekly 
reduced pressure to 138 mm., and below, and has con- 
tinued so over a period of several months. 

The author again emphasizes the fact referred to on 
page 248, viz,, that in hypertension caused by a failing 
heart, reduction in pressure can only be achieved by 
concussion of the 7th cervical spine. 

All emotions directly influence the heart and the 

caprices of the organ with its protean symptoms may be 

subdued by bromids. Any neurosis embraces the entire 

fleld of pathology and this applies in all cogency to the 

heart. 

Rest and a few doses of morphin are capable of 

completely altering the picture of a cardiac disease. 



461 



n 



Vagus- TONE and the sense organs. — If both nostrils 
are firmly packed with cotton one may excite the vagus reflex- 
ly through the trigeminus. Reference to this fact has already 
been made on page 297. Even though a paroxj-sm is not 
excited, one may auscultate after the cotton-test, the raks 
peculiar to asthma. 

It is only recently, however, that the writer has noted 
that the hvpertonicity of the vagus thus elicited includes 
practically all the branches of the vagus. Like results 
follow firm pressure on the posterior part of the external 
auditory meatus (supplied by the auricular branch of the 
vagus). 

If one cocainizes both nostrils (5^ solution suffices in 
the norm), one observes the following: 

1. Inhibitionof the w'scera/ tone (page 451), of the 
liver, spleen and heart, 

2. Inhibition of the stomach reflex and the lung 
reflex of dilatation. The lung reflex of contraction 
and the heart reflex persist. 
With these facts at our command, one need no longr 

equivocate with specious hypotheses in explanation of th 
reflexes of the cranial nerves (page 440). 

The nose is a very important reflex center and must 
be examined as a routine measure in determining the 
etiology of many diseases of vagal origin. AH kinds of 
refle.t disturbances including headaches, neuralgias, 
chorea and even epilepsy, may be due to a nasal anomaly 
and by treatment of a naso-pharyngitis, delleclion of the 
septum, enlarged turbinates, etc, it is possible to cure 
many disturbances. Reference has already been made 
tothediagnosisof cm^/iyjemoby aidofcocain (page 297). 
Asthma is often of nasal origin and paroxysms may be 
inhibited by saturating pledgets of cotton with a 10 per 
cent, solution of cocain and then introducing one into 

462 



Vagus Tone and the Sense Organs 

each nostril. If relief is obtained, one should determine 
from which side of the nose the paroxysm is excited. 
If, for instance, after cocainization of the right nostril, the 
paroxysm persists, and desists only after its application 
to the left nostril, one is occasionally justified in con- 
cluding that the attack is provoked by some abnormity 
of the nostril on the left side. One must not forget, 
however, that mild attacks of asthma may be annihilated 
by cocain to the nostrils despite the fact that there is no 
asthmogenic nasal area. Here we recall the fact that 
cocain anesthesia of the nose inhibits the lung reflex of 
dilatation without influencing the counter-reflex of con- 
traction. It is the exaggeration of the latter reflex 
which determines the jugulation of a paroxysm. When 
adrenalin arrests a paroxysm it does so by stimulation 
of the bronchoconstrictor fibers (page 457), and cocain 
(which is less efficient), acts by inhibiting the tonus of 
the bronchodilator fibers, thus enabling the antagonistic 
fibers to have imopposed sway. One may provoke 
sneezing, cough, dyspnea or an asthmatic paroxysm, by 
touching different parts of the nasal mucosa with a 
probe. Such areas cauterized with chromic, trichlor- 
acetic or glacial acetic acid may prove curative. 

The following are susceptible areas of the nasal 
mucosa: i. The anterior portion of the septum; 
2. The anterior end of the inferior turbinate. 3. Lat- 
eral wall of the nose slightly above the region of the 
anterior end of the middle turbinate; and 4. Upper 
part of septum about the tubercle. 

Irritation of the mucosa of the nasal septum opposite 
the middle turbinate bone will evoke an arrhythmia of 
vagal genesis. Here the irritation is conveyed, in- 
directly, to the vagus by the trigeminus. 

If the nasal mucosa has been cocainized its irritation 
by a probe will not evoke arrhythmia. 

According to the theory of Fliess, dysmenorrhea is often 
associated with nasal affections. He determines such asso- 

463 



ciation by noting whether the pains are influenced by 
cocainization (lo to 20 per cent.), of the nasal mucosa. 
Fliess further observes that when the hyperesthetic areas in 
the nose are irritated with a probe, the pains of dysmen- 
orrhea can be provoked. The latter observation was made 
by Fliess to contravene the assumption of others, that his 
results were due to suggestion in hysterical subjects, and 
that equally good results could be obtained if the cocain 
applied to the cervix, rectum, or some other mucous surfj 

My observations show that the proponent and his op- 
ponents are equally right and wrong. If one first elicits the 
reflex of the uterus (page 358), in a normal subject and then 
cocainizes the nostrils with a 5 per cent, solution of cocj 
the uterus reflex cannot be provoked during the action 
the cocain. 

Furthermore, cocain-anesthesia of any other mucosa 
is equally effective in abolishing the uterus reflex. In 
other words, anesthesia of a peripheral area dlminisbes 
vagus-tonus. When Fliess excites dysmenorrhea! pains 
by probing the nose, he merely augments vagus-tone. 

When cocain solution (5%) is instilled into the eyes 
all the vagal reflexes are temporarily abolished. 

We can now understand why Koblauck finds that 
nasal cocainization will temporarily inhibit labor pains, 
and that applications of adrenalin will excite them. 

Siegraund finds that gastric pains are inhibited by 
the nasal application of a 20 per cent, solution of cocain, 
which he considers diagnostic and he likewise establishes 
by [he same diagnostic- therapeutic method, the relation 
l>etween the nose and the genito-urinary apparatus 
(enuresis and maslurbalion). 

It will be evident to the reader, from what has pre- 
ceded, that the method of nasal cocainization proves 
nothing. It is only one of the many methods for dimin- 
ishing vagus-tone. By cocainizing the urethra, I find 
that one can inhibit the various visceral reflexes. 



and ^^ 
w»i^H 



Vagus Tone and the Sense Organs 

As we shall learn later, diminished vagus-tone may 
be effected by paravertebral pressure (page 467), and, 
after this manner, it is my routine practice to inhibit the 
motor and sensory reflexes of the vagus. 

The foregoing observations of the author lead one to a 
consideration of the interesting physiologic problem, m., 
whether the doctrine of specific nerve energies applies to the 
muco-cutaneous nerves, i. e.j whether there are specific 
nerve fibers giving only their own quality of sensation. 
This view is supported by Donaldson, who found that when 
cocain is applied to the nose or throat, the senses of pain 
and pressure are destroyed, leaving those of heat and cold. 

My observations show a very important clinical fact, viz., 
that there are specific muco-cutaneous nerves which preserve 
the tone of the viscera and that others exist which^ when irri- 
tated ^ diminish visceral tone (page 544). 

The facts thus elicited by clinical physiology must sub- 
stitute the observations of the physiologist. Visceral tone 
is therefore the resultant of not one, but of a summation of 
peripheral sensory stimuli, and that the continuity of tone 
may be blocked by annihilation of a single stimulus. 

It is for the foregoing reason that one is able to confirm 
the observations of Kast and Meltzer (Foot-note, page 58). 

There is yet another observation to which attention should 

be directed, viz,, that after nasal cocainization, in lieu of a 

uterus reflex, one elicits a powerful reflex contraction of the 

vaginal walls (vaginal reflex). This latter observation may 

be utilized in toning relaxed vaginae. Here the sinusoidal 

current is used at the same site for elicitation of the uterus 
reflex. 

In concluding this interesting subject of nasal re- 
flexes, let us recall the practical fact that, impaction of 
the nares with cotton will accentuate or provoke symp- 

465 



S p 



d y I 



loms of problemclU nasal genens, whereas nasal cocain- 
izalion v:il[ inhibit ihcm. 

The pharmacology of the ocular reflexes is dis- 
cussed elseivhere, (page 498). 

PsYCHOVAGus-TONE. — Psychic influences on the heart 
and lungs have been discussed on page 203, and it is import- 
ant to demonstrate such influences objectively. Reduction 
of vagus-tone may be of psychic origin. Physiologic ex- 
periments show that in fatigue of the nervous system, the 
nerve-cells, which in health are plump, large, and with easily 
demonstrated nuclei, become small and shrunken and the 
nuclei indistinct. In consequence of this enervation of t 
nervous system, reflexes are with difl&culty elicited and ( 
protracted. 

The author recalls a patient with a thoracic aneuiysm 
referred to him by Dr. A. J. Minaker. Wiihia a few 
treatments such cases show amelioration, but in this case 
the final beneficial results were delayed by grief following 
the death of a member of the family. Here, it was noted 
that during the period of grief, there was a considerable 
reduction of vagus- tone. 

Another factor is involved in psychic influences. 
Splanchnic siimulalion increases the content of epine- 
phrin in the blood and adrenal secretion is under the 
control of the sympathetic system. There is reason to 
believe from the investigations of Cannon and De La 
Paz" that emotional cjccitement stimulates adrenal secre- 
tion. It is eiidenl that when the sympathetic is stimu- 
lated, the tonidly of the vagus is reduced. Emotional 
disturbances conduce to symptoms suggestive of vagus- 
depression and sympathetic irritation; aortic-dilatation, 
inhibition of the gastro- intestinal apparatus, rapid heart. 
etc. I have often been impressed with the inconsistency 
of our conception of hysteria as a disease in which the 
will controls the body and produces morbid changes in 

466 



Paravertebral Pressure 

its functions. The fact is, the S3rmptoms of the disease 
are caused by stimulation of the sympathetic system and 
the latter is not imder the influence of the will. It is 
equally inconsistent to ask such patients to control their 
symptoms by exercise of the will. 

2. Paravertebral pressure. — ^We have shown under 
the preceding caption that pHocarpin^ increases vagus-tone 
and that atropin annihilates it. That adrenalin^ by stimu- 
lating the sympathetic fibers, puts the latter in a state of 
increased tonus, thereby resulting in a relative reduction of 
vagus-tonus. 

We shall now endeavor to show that augmentation and 
reduction of vagus-tonus may be obtained in a simplified 
and more expeditious manner by paravertebral pressure. 
The excitation of visceral reflexes by spinal pressure has 
already been noted on page 169. 

The points of exit of the spinal nerves are relatively 
superficial. Thus in a number of measurements, I found 
the exit at a point corresponding to the 7th cervical vertebra 
to be at a depth of 2.6 cm. (approximate only), almost in a 
direct line with the corresponding spinous process and the 
distance between the two exits corresponded to an average 
width of 2 cm. 

At the first lumbar vertebra, 4.5 cm. represented the 
depth and 5 cm., the width of the exits on either side. 

For making pressure I employ the simple apparatus 
shown in Fig. 112. The prongs of the instrument are separ- 
ated by a distance of 5 cm. If one makes pressure (the 
prongs approximating the intervertebral foramina on both 
sides), at a point corresponding to the seventh cervical spine, 
vagus-tone is increased and decreased or abolished whe7i 
pressure is applied at a point between the third and fourth 
dorsal spines. Pressure is maintained for about one minute. 

467 



» 



S p 



d 



I 



a p y 



The author assumes that at the former point, the pressor, 
and at the latter situation, the depressor fibers of the vagus i 
are stimulated (page 232.) 




diignosis and trealmeni for making bilalcral pte^ure oii lire roots of the spinal 
lierves at their exit from the inlervenebral foramina. The inslniraent with a ^ngle 
prong is used for demonstrating areas of paravertebral tenderness {vide, page 6e). 

The depressor nerve is the most important centripetal 
nerve of the heart, and while existing as a separate anatomic 
structure in warm-blooded animals, its homologue has been 
468 



Paravertebral P 



r e s s u r t 



tnu^ in the human with central connections in the vagus 
and endings in the walls of the ventricle. 

Fig. 113 shows the origin of the depressor nerve in the 
rabbit 




Fig. 113. — Scheme of the cardiac nerves in the rabbit (Landois and Stirling). 
P, poiu; M, medulla oblongata; Vag, vagus; 5L, superior, IL. inferioi laryngeal; 
•c, superior cardiac or de^eijor; ic, inferior cardiac or cardio-inhibilory; H, heart. 

Methods of increasing vagus-tone. — Elsewhere (page 
228), reference has been made to maneuvers for exciting 
the tone of the vagus and the practical ones may be recapitu- 
lated as follows: i. Pressure at the 7th cervical spine by 
aid of the instrument shown in Fig. 112. 2. Position of the 
head, as shown in Fig. 65, and so maintained while observing 
the vagal phenomena. 3. Pressure in an intercostal space. 

Preference is accorded to the first me*' ' «". 

assistant is present, althou^ when oat 
469 



t h 



a p 



intelligent patient, the second method suffices. Even with- 
out an assistant, one can demonstrate the exalted vagal 
reflexes, if pressure is made at the 7th cervical spine with the 
instrument, or in an intercostal space (firm pressure), with 
the finger, and one proceeds at once with percussion (soi 
visceral reflexes do not exceed the duration of a minute] 
However, one may note in the following table the duratioi 
of the lung reflex of dilatation when pressure is made for 
one-half minute. Insomuch as the degree and duration of 
descent oj the lower lung-border is most conveniently utilized in 
testing vagus-tone, a comparison of methods is cited in the 
normal subject: 

COMPARISON OF METHODS. 



tne 
ith^l 

iot^^l 



„™„ 


"Esr 


"XVHf 


DESCENT 


sides of Ihc jlh tervical spine. . 


One-half 

minute. 


5 cm. 


9 mmwM 


Forcihlt cxtctiMon of ihc neck. 
(Fig. 6s). 


One-halt 


4 cm. 


,„ .teuJ 


Pressure in an inlereostal space. 


One-halt 


3 cm. 


■ "»»" 


Direct concussion of the 7th cervi- 
cal spine. 


One-haU 


♦ cm. 


al minutes 


poles on either side of ihe 7th 
cervical spine. 


One-haif 
minute. 


S.jcm. 


■■"i 


High-frequency current on either 
side of 7lh cervical spine with a 
double vacuum electrode (Fig. 
100). 


One-half 


S-Scm- 


J 



Vagal- PHENOMENA. — During the time pressure is maq 
at the 7th cervical spine with the instrument shown in Fig.il! 
one notes the following: 

470 



Vagal Phenomena 

1. Augmented tone of the heart, aorta, lungs, stomach, 

liver, spleen and intestines, manifested by increased dulness 

of the organs in question and better definition of their 

borders.* 

Reference has already been made to visceral-tone 
(page 451), but to further appreciate the importance of 
this subject, let us refer to the heart. During diastole, the 
walls of the heart are relaxed but this diastolic relaxation 
varies with the tonicity of the heart-muscle. Fibers exist 
in the vagus of the frog, which, when stimulated, increase 
the tone of the myocardium. When one makes pressure 
as above, the cardiac muscle normally relaxed becomes 
rigid (diastolic rigidity). I employ this method for 
facilitating the percussion of the heart and in testing its 
lone. If the myocardium is normal, the precordial dul- 
ness is accentuated after the above maneuver, whereas, 
if diseased (diminished tone), the degree of dulness is 
unchanged. Forcible extension of the neck may likewise 
be utilized in testing the tone of the organs specified and 
determining their borders by regional percussion 

2. Contraction of the pupils (this is not constant). 

3. Closure of the crico-thyroid space. 

The latter phenomenon is best elicited when the 
finger-tip is placed at the side of the crico-thyroid mem- 
brane. Pressure brings out the phenomenon best. If 
not detected easily have the assistant make intermittent 
pressure at the 7th cervical spine. The crico-thyroid 
muscle is supplied by the superior laryngeal (branch of 
the vagus) nerve, and it produces tension and elongation 
of the vocal cords. An hysterical paralysis of the vocal 

*In association with the augmented visceral tone, there is visceral contraction^ and 
this contraction is greater, e. g., of the stomach at the 7th cerNical spine than 
at the upper lumbar spines (page 316). Thus, the degree of stomach-contrac- 
tion when the first three lumbar spines are concussed is only 2 cm., but 4 cm. 
after concussion of the 7th cervical spine. The same observation applies to the 
spUen. 

471 



S p n d y I 



cords may be diagnosed objectively by closure of the 
crico-thyroid space by tbc suggested maneuver. 

4. Eosinophilia. 

5. Hyperesthesia of the fauces. 

6. Descent of the lower border of the lung (lung refli 
of dilatation). 

7. Diminution in volume of pulse and slowing to extinc- 
tion . 

It is more convenient to select the lower border of the 

lung posteriorly on either side. The lower border is first 
determined by percussion, after which pressure is made 
for one-half minute and the border again determined. 
In the norm the descent is about 4 cm. In vagus-hyper- 
Ionia, it may descend 6 cm., and in hypotonia, it may 
descend only z cm., or not at all. Pressure between the 
spines of the third and fourth vertebrae causes the lower 
lung-border to recede. Increased vagus-tonus is gener- 
ally associated with a low lung-border and its converse 
condition with a high border. 



Methods for DECREASmc vagus-tonus. — i. PressuH 
with the instrument (Fig. 112), ata point between the thin 
and fourth dorsal spines. 

2. Pressure behind both ears. 

During the time such pressure is made one notes I 
following: 

1. Diminished tone of the heart, aorta, lungs, stomad 
liver, spleen and intestines. 

2. Annihilation of the reflexes of the lungs, stomad 
heart, aorta, spleen and intestines. 

3. Pupillary dilatation. 
,V Widening of the crico-thjToid space. 
4- Anesthesia of the fauces. 



Pressure Behind Both Ears 

5. Ascent of the lower lung-border (lung reflex of con- 
traction. 

6. Pulse diminished in volume and rapidity increased. 

In this connection, it is necessary to note the approx- 
imation of the sites for increasing vagus-tone (7th cervical 
spine) and for diminishing it (between the 3d and 4th 
dorsal spines). A physician whose results were futile in 
the treatment of an aneurysm by concussion made the 
egregious error of employing a large concussor which 
embraced simultaneously the areas for increasing and 
diminishing vagus-tone. 

2. Pressure behind both ears. — ^The observations of 
Milligan and Home have been confirmed by others : pressure 
applied to the mastoid processes generally relieves pain (due 
to faucial inflammation), in swallowing. Hald explains the 
effect as due to counter-irritation of the skin at a point 
where the sensory nerves are closely connected (centrally), 
with the sensory nerve-supply of the tonsils 

In investigating this subject, the author finds that 
pressure between the 3d and 4th dorsal spine is the more 
efficient of the two methods. In both methods, dysphagia 
(whether due to faucitis or esophagismus), is combated 
by inhibition of the sensory fimctions of the vagus. 
Even in the norm, one may anesthetize the throat for 
practical purposes (laryngoscopic examination or intro- 
duction of a stomach-tube), by firm bilateral pressure for 
one or two minutes at the site noted (between the 3d and 
4th dorsal spines). The anesthesia however, is limited 
in duration but it may be prolonged by resumption of 
pressure. In pressure behind both mastoids the same 
vagal phenomena ensue as were cited when pressure is 
made between the third and fourth dorsal spines. By 
bilateral mastoid-pressure one probably compresses the 

473 



auricular branch of the vagus which appears cutaoeously 
behind the ear. 

One must note another tact when vagus-tone is 
diminished by pressure between the 3d and 4th dorsal 
spines, viz.: dilatation of certain \-iscera. Thus, an 
aneurysm which shows a diameter of 4 cm., by percussion 
is reduced to i cm. when vagus-tone is increased by pres- 
sure at the 7th cerrical spine and increased to 7 cm.. 
when vagus-tone is decreased. Pressure or concussion of 
the region for reducing vagus-tone, produces greater 
dilatation of the aorta than the conventional site for 
eliciting the aortic reflex of dilatation (page 256). Thus, 
an aneurysm measures 4.8 cm. in the transverse diam- 
eter; concussion of the gtb-izth dorsal spines gives a 
measurement of 8 cm., and 10 cm., after concussion be- 
tween the 3d and 4th dorsal spines. 



Therapeutic results. — Cures show the nature of 
diseases. Draper made the sapient observation that: 
"Mastery of all the sciences upon which medicine is founded 
does not make the physician . . . until he learns how 
to construct out of them the special art which enables him 
to cure disease." Broussais observed that the real physician 
is one who cures, A story is related of an American phy- 
sician who was shown through a large pathologic laboratory 
in Paris, and was wearied looking at shelf after shelf loaded 
with pickled specimens of organs and tissues from people 
long since dead. At last he turned to the great pathologist 
and said: "Great God! where are the people you have 
cured ?" 

It is difficult to charm ache with air, and agony wid 
words, and unless we call a halt on scientific medicine { 
we shall soon regard it as a misdemeanor should the patia 
be so presumptuous as to demand a cure. 

A short time back, the author sent to a leading ( 
474 



Therapeutic Results 

jggglgBgBaBaaBSBBBa^SSSSSSBSBSSSSS^SSSSSmSSBSKBS^SS:BSBSS^BSBSSSS, 

medical journal, a report of 40 cases of aortic aneurysm, 
symptomatically cured. Most men will agree that the cure 
of aneurysms should be considered one of the greatest con- 
tributions ever made to scientific medicine. The report, 
however, was refused publication, based on the assumption 
that, insomuch as aortic aneurysms were incurable, any 
reports to the contrary were in violation of our accepted 
theories concerning the pathology of the disease. 

The physio-therapeutic methods suggested in this book 
for inhibiting or exciting visceral reflexes are equally available 
in diminishing or increasing vagus-tone. In the application 
of our method, whether it be concussion, pressure or electric- 
ity, we must always remember that to increase vagus-tone, 
we confine ourselves to the bilateral paravertebral area 
corresponding to the 7th cervical spine, and when vagus-tone 
is to be diminished, the site of election is between the 3d 
and 4th dorsal spines. S)niiptoms, in some affections, abate 
rapidly, whereas in others the results are more tardy. We 
may gauge our results by noting the degree of descent and 
position of the lower lung-border. 

If the symptoms do not abate despite the augmentation 
or decrease of vagus-tone, then vagus-tone is in no wise 
related to the symptoms (page 451). 

In the choice of the method to be employed, the physician 
can determine for himself the one most effective for causing 
either a descent (increased vagus- tone), or ascent (dimin- 
ished vagus-tone), of the lower lung-border. 

When ability is lacking in this regard, then concussion 
should be given the preference, insomuch as it is easy of 
application and generally reliable. Over-treatment must be 
avoided to prevent exhaustion of the reflexes. 

The following table represents the degree of ascent of 
the lower lung-border after different methods to the 

475 



Spondyloth 



region between the third and fourth dorsal spines for 
decreasing vagus-tone: 

CONCl'SSION 2.3 

Rapid sinusoidal current 1.6 cm. 

Slow sinusoidal cukrent 1.6 

Pressure 1.6 cm. 

HiGH-FHEQUENCy CURRENT No aSCeDt. 




The duration of rtlraction ivas greatest u-itli tlie ^low 
sinusoidal current; one pole applied on each side of the 
spine between the third and fourth dorsal vertebrae. 

In many instances the patient is provided with two 
ordinary base-knobs (Fig. 114), and he is instructed lo 
have some member of the family make firm pressure four 
times daily on either side of the spine {corresponding to 
the area lo be influenced) for a period of time not ex- 
ceeding one minute. To protect the skin and to locate 
the site of pressure the physician should apply a narrow 
strip of adhesive plaster. 

One of my patients suggested screwing the base-knobs 
on the back of a chair or into a wall at a convenient 
476 



Therapeutic Results 

height and by bradng the feet, the patient can exert 
pressure himself. 

In locating paravertebral tenderness, the phyddan 
will find the base-knob very convenient. 

Another and most effective method which can be em- 
ployed by the patient at home for increasing vagus-tone, is 
that of extending the muscles of the neck, as shown in Fig. 65. 




Fig. 115. — Heart rHcx elidted by the method of extending the muscles of the 
neck (viiU, Fig, 65). The amplitude of the reflex is indicated by the reduced area 
of cardiac dullness extending from without to within the nipple. 

'This may be executed twice or thrice daily, and about 
twenty forcible extensions can be made at a seance. 

In affections of the heart and other diseases caused by 
diminished tone of the vagus, my patients are instructed to 
execute these exercises in addition to treatment at my office. 
The effect of such exercise on a dilated heart is noted in 
Fig. 115- 

Fig. 116 represents an apparatus for applying bilateral 
paravertebral pressure. Suspended from the middle bar is 
a suspension apparatus which is quite independent of the 
other. 

477 



Spondyioih 



Suspension Treatmenl, when first advocated for loco- 
motor ataxia, was employed indiscriminately and soon 
passed into desuetude. With this treatment the patient 







js for applying bilaleral paravertebral piessure. Adjusted 
I ilie bars are two pieces which can be raised or lowered. The front piece is pro- 
vided with a cushion which is fixed lo the chest with a screw and is used for countcT- 
piesaure. The back piece is provided with two small knobs (barely visible in tbe 
il lustration), which are fixed over a definite vertebral area and by means 
any degree of pressure can be made. Suspended from above is a suspeo^n ^ 
paratus wMch b independent of the other. 

is suspended in a Sayre apparatus. This treatment is 
still used by (he author as an invaluable method in some 
cases for the relief of pain, bladder-disturbances and 
impotency. The method is curative when pains simu- 
lating lumbago are really due to adhesions in the verte- 
478 



Diseases Caused by Vagus-Hyper ton ia 

bral articulations. Suspension was used in 1829 by 
J. K. Mitchell, of Philadelphia, for affections of the cord 
secondary to vertebral disease. The investigations of 
Motschutkowski, show that during suspension, the nerve- 
roots pass from a horizontal to an almost perpendicular 
position and the cadaver was increased in length. 

I have found that, during suspension, the tone of the 
viscera is augmented. 

It is for the latter reason, if for no other, that suspen- 
sion may be regarded as a valuable method of treatment. 

Effects, almost equal to suspension may be achieved 
by having the patient sit on the floor or a table and then 
forcibly flexing the head and trunk upon the thighs, 
while the lower extremities are kept straight. 

DISEASES CAUSED BY VAGUS-HYPERTONIA AND VAGUS- 

HYPOTONIA 

Diabetes mellitus. — The great majority of cases of 
this affection observed by the author have been associated 
with vaguS'hypotonia, and he has treated his cases by the 
method suggested on page 281. Since the results were pub- 
lished on page 283 he has encountered a group of cases 
yielding better results and even though no s)niiptomatic cure 
was effected in several cases, the tolerance for carbohydrates 
was augmented. In two cases with a pronounced history of 
heredity (several members being similarly afflicted with 
diabetes), no results were achieved. The only restriction 
respecting diet was the avoidance of any excess of carbo- 
hydrates. 

In several individuals with alimentary glycosuria, the 
assimilation limit for carbohydrates was increased by aug- 
mentation of vagus-tone by concussion. The test employed 
was that of Naunyn : two hours after a breakfast consisting 
of a roll and butter, with coffee, 100 grams of glucose, given 

479 



S p 



d y I t h 



P 



in solution, ought not to cause a glycosuria. If glycosuria 
ensues, the individual shows a diminished capacity for ware- 
housing carbohydrates and true diabetes may eventually 
follow. The liver is the probable source of sugar production 
and is in turn controlled bj' the pancreas and suprarenals 
(the pancreas playing the rok of inhibition, and the supra- 
renals that of stimulation in sugar production). The secre- 
tion of the thyroid inhibits the function of the pancreas as is 
demonstrated in the tendency to glycosuria in hyperthy- 
roidism. After thyroidectomy, the inhibitory influence of 
the pancreas on the liver is so powerful that it is almost 
impossible to produce glycosuria. Modem writers regard 
the glycosuria ensuing from puncture of the medulla to be 
due to suprarenal stimulation, which excites the liver to an 
increased output of sugar. The puncture of the medulla 
stimulates the left sympathetic nerve and this stimulation is 
transmitted first to the left and then to the right suprarenal. 
If the left suprarenal is separated from the left sympathetic 
nerve, glycosuria does not follow puncture of the medulla. 

If the vagus-tone is normal, adrenalin (given hypoder- 
matically), will not cause glycosuria, nor will the ingestion 
of glucose up to 300 grams. Atropin diminishes or abolishes 
vagus-tone and in individuals with reduced vagus-toni 
even small doses may cause glycosuria. 

One also knows that pilocarpin, which augments va| 
tone, will suppress glycosuria from adrenalin. 

In several instances I have found glycosuria in 
ceptible individuals to follow paravertebral pressure bet^veen 
the 3d and 4th dorsal spines. This maneuver abolishes or 
diminishes vagus-tone (page 472). 

In practically all of my diabetic patients I have found 
enlargement of the liver and the signs of diminished tone of 
the splanchnic circulation. 



Ishes I 

iveen^^l 




Diabetes M e I I i t u s 

Dr. H. C. Sawyer reports* the following case of diabetes 
treated according to the method of the author : 

"Female, fifty-two years of age, and weighing about 
i8o pounds presented herself April 9, 1910, with a history 
of incessant thirst and frequent urination owing to the ex- 
cretion of enormous quantities of urine. The latter at 
this time had a specific gravity of 1,040 and contained 
eight per cent, of sugar; the reaction for diacetic acid was 
positive. 

The following represented the average daily menu 
prior to the commencement of treatment which consisted 
of daily concussion of the seventh cervical spine of an 
average duration of about ten minutes: Breakfast. — 
Coffee, toast, and scrambled eggs. Luncheon. — Cold 
chicken, chop, asparagus, potatoes, and several slices of 
bread. Dinner. — Soap, egg salad, chicken, several 
slices of bread, asparagus, ice cream, and coffee. The 
foregoing diet was permitted during the treatment. 

Within one week, polydipsia and polyuria had com- 
pletely evanesced, but sugar continued in the urine vary- 
ing in percentage from 5 to 0.77 per cent, on May 7, 19 10. 

After the latter date and up to the present time of 
writing (July 30, 191 1.) there was absolutely no trace of 
sugar in the urine with the exception of one day when it 
reappeared temporarily after the patient partook, at a 
picnic, of a bottle of root-beer and ingested many other 
elements containing an excess of sugar. 

Comments. — The reappearance of sugar on a single 
day was of no moment and indicated a physiological 
glycosuria which occurs in certain persons of apparently 
good health after the rapid ingestion of an excessive 
quantity of carbohydrates. From the evidence pre- 
sented, the case in question can only be regarded as one of 
true diabetes mellitus. The rationale of the method con- 
sists of diminishing the quantity of blood flowing through 
the liver by augmenting the tone of the splanchnic blood- 

481 



S p n d y I 



t h 



vessels and thus improving the nutrition of the hepatic 
cells concerned in ihe warehousing of carbohydrates. 

By the method of percussing the liver as suggested 
by Abrams, enlargement of the organ may be demon- 
strated in diabetes and a diminution of its volume may be 
noted after a single concussion sifance. The latter fact is 
probably due to a diminished volume of blood in the liver 
and is not a true liver refleit such as is elicited by con- 
cussion of the spinous processes of the first three lumbar 
vertebrae. 

Twenty S(?ances of the concussion treatment in the 
foregoing case were necessary before the sugar disap- 
peared from the urine." 

It is the practice of the author, before commencing 
treatment to get the urine sugar-free and then to add, 
gradually, small quantities of carbohydrates to the die- 
tary. 
Diseases of the thyhoid gland. — Organothen 
has demonstrated the causal relation between this gland am 
a host of diseases. It has already been shown that the 
physiologic tonus of the vagus is probably dependent on the 
thyroid secretion. In diseases due to diminished thyroid 
secretion (hypothyroidism), vagus-tonus is increased and 
conversely diminished when the secretion is excessive 
(hyperthyroidism). 

Hypothyroidism. — Insufficiency of the thyroid glac^ 
may be recognized by the tests on page 488, et seq. Th^ 
diagnostic- therapeutic test by the administration of thyroid 
is equally valuable. Diseases caused by hypersecretion are 
aggravated, and those due to hyposecretlon, are ameliorate 
or cured by thjToid. 

One must give thyroid to obtain physiologic ancT nd 
toxic effects (thyroidism). The symptoms of thyroidism 
indicate that the thyroid dosage must be reduced or inter- 
dicted. The signs of thyroidism are: anorexia, emaciatioi 
482 



Diseases of the Thyroid Gland 

perspiration, insomnia, headache, nervous excitement, heart 
palpitation, tachycardia, tremors, prostration, etc. Inso- 
much as thyroid diminishes vagus-tone (page 459), it is not 
surprising to note that glycosuria may attend its adminis- 
tration. Thyroid function is identified with the metabolism 
of carbohydrates, insomuch as it has been shown that the 
administration of thyroid interferes with the retention or 
assimilation of carbohydrates. Thyroid should never be 
given in the presence of symptoms suggesting exophthalmic 
goitre. 

The dessicated thyroid is a yellow powder made from 
the thyroid glands of sheep, and the dose varies from \ grain 
to 1 5 grains. It is more convenient to give it in tablet form, 
and reliable tablets are made by Merck, Parke, Davis and 
Co., and Burroughs Wellcome & Co. It is also given as 
the raw, fresh gland of a sheep, on bread, beginning with 
the eighth part of a gland and gradually increasing the 
amount. The latter mode of administration is indicated 
when the dried preparations cause thyroidism. Th5rroid 
has been given for every imaginable disease, but there are 
certain affections which empiricism has taught are identified 
with subsecretion of the gland. 

In children hyposecretion and athyrea (absence of secre- 
tion), are associated with slow and stunted growth, retarded 
pulse, phlegmatic temperament, juvenile obesity, delayed 
puberty and cretinism. 

In girls, delayed menstruation, amenorrhea, chlorosis, 
hysteria and epilepsy contribute to the symptomatology. 

In the adult one finds myxedema and an abnormal 
tendency to obesity. 

Many symptoms of senility have been attributed to 
hyposecretion, notably lesions of the skin (nutritive distur- 
bances and eczema). 

483 



H p 



t h 



r a p y 



In certain Umok of mdanckoUa or hysteria, asodaled 
with deprewtion and tardy ceretvation, tbyrmd has been 
phemifnenally efficient. Peabody," avers that 75 per oent. 
'rf (>a(icnts who die from mental disease show anomalous 
Ihyrmd glands. 

Vomiting of pregnancy is often arrested by tfayrnd ad- 
ministration, and many competent observers regard thyrmd 
'M an cxrcllent treatment for eclampsia. 

Epileptic attacks associated with the menstrual period 
have Ijcen cured t>y thyroid. Entailment of the thyroid 
fflund may tx; associated either with a diminished or excessi^-e 
thyroid secretion. The enlargement may be structural 
(hypcrpla-Htic), or vascular. Vascular enlargement (peculiar 
to exophthalmic goitre), may be distinguished from hyper- 
pliisiu (goitre), by the fact that a murmur or thrill is elicited 
when the gland is pressed upon. 

IIyi'icktiivhoidism. — In hyperthyrea, vagus-tone is 
(liminiHhcd and this hypotonia is realized by the tests on 
page 471, et seq. 

Little can Ix: expected of the diagnostic-therapeutic test 
for the reason that the various antithyroid preparations are 
iticonstiint In action and they are equally lauded by some 
and corHlcmned by others. 

Sym[)loms of hyperthyrea are accentuated by certain 
prcpiirations descrilxid on page 453. 



Hyperthyroidism 

This disease occurs more frequently in women than in 
men. 

Transitory hyperemia of the gland occurs in females at 
puberty, menstruation and pregnancy. It is not unlikely that 
many symptoms at these periods are caused by hyperthy- 
roidism. The vascularity of the thyroid gland is enormous. 
Every minute, the quantity of blood passing through the 
gland is equivalent to six times its weight and it is said that 
it is twenty-eight times as vascular as the head, and five and 
one-half times as vascular as the kidney. 

The symptomatology of exophthalmic goitre is made up 
of the classic tetrad: struma, tachycardia, tremor and exoph- 
thalmos. 

The recognizability of such symptoms is facile. It is the 
recognition of minimal hyperthyroidism, which demands 
diagnostic acumen. Let us, however, first interpolate cer- 
tain facts concerning the thyroid heart. 

Cardiac disturbances may be associated with all forms 
of goitre and conduce to the condition known as thyroid 
heart (Kropfherz). Goitre, however, may be secondary to 
cardiac disease (cardiac goitre). The cardiac disturbances 
of a goitre may be due to essentially mechanic causes (pres- 
sure on the trachea, veins and sympathetic ganglia). When 
pressure is exerted on the sympathetic, tachycardia and 
exophthalmos (usually unilateral) ensue, leading to a clinical 
picture known as pseudo-exophthalmic goitre. 

Cardiac disturbances may also be caused either by a 
deficient or excessive secretion of the thyroid gland In the 
former {cardiopathia thyreoprivea), the dominant symptom 
is cardiac weakness, insomuch as vagus- tone is largely 
dependent on the secretion of the gland which is deficient. 
Early arteriosclerosis is another condition associated with 
hypothyroidism. 

485 



*< 



S p 



t h 



a p 



Insatiily may be associated with a disfunctionallng 
thyroid and psychoses concurrent with exophthalmic goitr* 
are not infrequent. The psychotic symptoms represent c 
of two groups: maniacal agitation or a depressive type. 
Some authorities claim that chronic paranoia, dementia 
precox and even general paresis may be associated with 
exophthalmic goitre. 

The fact must be emphasized that hyperthyroidism i 
be present without visible or palpable enlargement of I 
thyroid gland. 

The active principle of the gland is iodothyreoglobulin. 
Thyreoglobulin is manufactured within the cells and acquin 
its iodin from the blood. 

In hyperthyroidism, when an excessof iodothyreoglobulirf 
is thrown into the blood, metabolism is augmented (loss of 
weight), and there is a stimulation of the peripheral nerves. 

The early recognition of atypic forms of hyperthyroidism 
[formes fritstes) is of great importance in determining the 
etiology of many obscure affections which masquerade under 
a medley of names. The symptoms peculiar to hyperthy- 
roidism are accentuated by factors which augment the vas- 
cularity of the gland or decrease vagus-tone. Such factors 
are: menstruation, pregnancy, emotional disturbances (which 
diminish vagus-tone, page 466), sexual excitement, genital 
disturbances (chiefly uterine), infectious diseases (notably, 
influenza), coffee, tea, alcohol and certain drugs (iodids 
and especially, thyroid extract). 

The fact that the thyroid gland is more active in worn 
accounts for the predominance of their nervous and hystei 
cal symptoms and the fact that exophthalmic goitre occiu 
more frequently in women than in men. 

Menorrhagia in young girls and women is often 1 
486 



Hyp e r t h y r o i d i s m 

symptom of hyperthyroidism, whereas hypothyroidism is 
associated with amenorrhea and chlorosis. 

Menorrhagia due to hyperthyroidism may be con- 
trolled by tablets of mammary extract in doses of about 4 
grains taken thrice daily. The tablets must be crushed 
by the teeth before swallowing. 

Menopause symptoms are unquestionably associated 
with hyperthyroidism. Among other early symptoms are, 

1. Cardiac signs; palpitation and irregularity, increased 
pulse-rate, attacks of tachycardia and throbbing of the 
arteries. Digitalis has little or no action on the cardiac signs. 

2. Psychic signs: mental excitement, restlessness and 
insomnia. The exalted states ensuing from wine or coflFee 
are probably caused by a transient hyperthyroidism. 

3. Octdar signs: widening of the palpebral slit, staring 
without winking for a considerable time and inability of the 
lids to follow the eyeballs when vision is directed at the 
descending finger of the physician. In the author's exper- 
ience when the lid does follow the finger, it drops in toto 
and not gradually. 

The author has noted an accentuation of the latter symp- 
tom (v. Graefe's sign) when the finger of the physician is 
directed downward in an oblique direction. He has further 
noted a slight spasmodic retraction of the lids when vision 
is directed downward in an oblique direction. When the 
patient first looks at an object, there is usually a spasmodic 
contraction of the upper-lid (Kocher-Boston sign). 

4. Nutritional sign: Loss in weight despite good appe- 
tite and digestion. 

Among other early signs are : Feeling of heat, elevation 
of temperature, flushes, perspiration and a fine tremor. 

The tremor is best observed when the patient is 
directed to spread the fingers. In hyperthyroidism, not- 

487 



S p 



d 



s k 



a p y 



ablj in euujifhtliahnir gnitni, I Iibv innyf i; ifflifmnrT of 
the fingers to became ariflHtneti yf^aasn -g/wnntif: Enf t&s 
tendenqr espedaDy irnplingtyt ^k iniailk .bii£ ijozdt 
finger. 

There is aaodier *iytnjiitim -vdiidi 3 Ixevs tcaenred 
and that is dyspmea am aaerHmL. T& s^naqamL 3x0.7 ^ 
caused hy a dUaied aorta, a nrmffrrinn -^^^ud: ik r»r] 



JJimJ^ 



associated in& czoplxdialnnc grnnr jmd ivt^m^ b ca^^slhr 
recognized bj caxcfnl percnssiaxi (pagp £5^>- ILndxr 
directs attention to teiuiemeas aJ "Akt duTi iid. a fjs&^^^c 
blowing over the thjroid ajlznes. jmd a .dicraismscac 
blood picture: leuoocjtcs ha]f as mxmamK £s sszal, 
neutrophiles reduced aiMl IjmphocTfees t«5ix ^ •nnrrnal 
figure. In the absence of this cniirt i iifl Uaod-pktaie. 
he will not operate. 



The symptoms of h3rpersecretioD and In 
I he thyroid may be recapitulated as folkivs: 



of 



Symi^tdms of Hyperthyroidism 

1 1 YPKKTIf YROIDISM. 



AXD Hypothyroidism^. 

H u o mviom isM. 



I. History of fatigue and slow 
onset. 

a. More common in adoles- 
cence than in middle life 
and in women. 

3. Outaneous flushing; tachy- 

cardia; manifest overac- 
tion of heart; pulsation of 
cervical vessels; all in- 
creased hy exertion; blood 
pressure 120-130. 

4. Mental instability and ex- 

citability rather than men- 
tal alertness; tremor; rest- 
lessness; (juick, jerky 
movements of extremi- 
ties; insomnia. 



1. Tbesame. 

2. More oommoQ during and 

after middle life and in 
women. 

3. Flushed skin over malar 

prominences only, marked 
pallor elsewhere; slow 
pulse; blood-pressure us- 
ually below 120. 

4. Mentality sluggish, rather 

than dull; headache; in- 
sonmia with changes to 
sonmolence only in ter- 
minal stages; slow move- 
ments. 



488 



Hyperthyroidism and Hypothyroidism 



Muscular weakness and in- 
ability to withstand ordi- 
nary fatigue. 

Exophthalmos generally 
present in some degree, 
and the more marked it 
is the worse is the prog- 
nosis. It is often absent 
in the early stages. 



5. The same. 



7. Goiter of variable size and 

consistency. Its vascu- 
larity and density give 
some indication of the 
relative importance of the 
thyroid in the general 
disturbance; goiter is 
often imperceptible in the 
early stages. 

8. Appetite abnormally good 

and out of proportion to 
the evident poor nutrition; 
movements regular or 
diarrhdc. Thirst con- 
stant. 

9. Skin moist with a subjective 

feeling of heat. 

10. Temperature 99 to loi. 

11. Blood shows relative lym- 

phocytosis, anemia slight 
or absent. 

12. Menstruation irregular or 

absent. 

13. Urine in nitrogen partition 

shows excess of creatin 
and diminished creatinin. 



6. 



No exophthalmos except in 
those who have passed 
through a preceding 
Graves' disease. In place 
of it there is a charac- 
teristic puffiness and 
edema around the eyelids 
and in the supraclavicular 
regions and on the back 
of neck and below the 
knees. 

Goiter is common, but by its 
consistency and absence 
of vascularity suggests a 
functionless organ. 



8. 



Appetite poor; apparently 
good nutrition. Consti- 
pation. No thirst. 



9. Skin dry and scaly; subjec- 
tive feeling of cold. 

10. Temperature subnormal. 

1 1 . Negative, anemia regularly. 



12. 



13" 



Regular but scanty, occas- 
sionally excessive. 

Negative; albumin some- 
times present. 



489 



Spondyioth 



The TREATMENT of cxoplitlialmic goitre is equally appli- 
cable for the minor and atypic manifestations of hyperth* 
roidism. 

In the conventional medical treatment, which rangi 
from Galvanization of the cervical sympathetic and exposure 
to the X-rays to the use of specific sera, the results are uncer- 
tain and recurrence is the rule. 

Respecting operative treatment (thyroidectomy), the i 
suits achieved by Kochcr (who has had the largest experience -J 
in such cases), arc as follows: absolute and permanent cure 
in 83 per cent., and 3.5 per cent, of deaths. C. H. Mayo 
had 9 deaths in 176 cases. 

Removal of the sympathetic ganglia (sympathectomyj 
on both sides is a procedure unattended by good results. 

The author's method of treatment (page 2S0) is practi4 
cally a specific in hyperthyroidism and the results are immedJ 
iate and usually permanent. Recurrence of symptoms 
is transient and associated with factors which augment the 
vascularity of the thyroid gland. The first symptoms to 
yield are tachycardia and cardiac irregularities, nervousness^ 
and perspiration. Exophthalmos is the most resistant sig 
and may yield synchronously with the other signs, it may 
improve after treatment is suspended or it may be permanent. 

Operations yield no better results, for in cases of long 
standing the exophthalmos is permanent owing to the deposlt- 
of orbital fat which causes the eye to protrude even thoug^l 
the muscle of Miiller is no longer contracted. 

The fxoplithalmos and separation of the lids in Exo- 
phthalmic goitre is caused by contraction of Miiller's 
muscle which is iunervated by Ihe cervical sympathetic. 
This muscle is attached to the bony wall of the orbit and 
is inserted into the sclerotic coat of the eyeball and the 
upper or lower lids. 

490 



Exophthalmic Goitre 

Reports received from many physicians, respecting 
the author's treatment of exophthalmic goitre are very 
encouraging. In several instances, only the methods of 
concussion shown in Figs. 2 and 3 were used. 

One physician writes, "in one week tachycardia 
reduced from 160 to no, enlargement of thyroid gland 
decreased about one-half, although exophthalmos is the 
same." 

Another reports, "I have never witnessed such rapid 
and marvelous results in the treatment of a disease." 

Another says, "Within three weeks practically every 
symptom disappeared but at the next menstrual period 
some symptoms recurred but have not reappeared up to 
the present time of writing." 

A physician, whose enthusiasm regarding the author's 
method was dictated by results, observes as follows: 
"It is only a question of time when physicians will and 
must recognize your specific treatment and when it will 
be regarded as criminal negligence for the physician to 
invoke surgery before giving your method a trial." 

A physician reported, "The symptoms were aggra- 
vated." On inquiry, I found that he was concussing not 
only the 7th cervical spine, but likewise the upper dorsal 
spines (which decreased vagus-tone). I have never 
heard further concerning his results. Any of the methods 
for increasing vagus-tone as suggested on page 469, are 
available in treatment. 

Dr. M. Tumbull cites one case with a history of 
exophthalmic goitre for 1 5 years. Despite an operation 
(ligation of thyroid arteries), the enlarged gland and car- 
diac signs persisted. Within 2 weeks, no gland could be 
seen nor palpated and the cardiac signs, tremor, etc, 
disappeared. At one menstrual period, the gland en- 
larged for 2 days. 

In this patient, a woman of 28, the hair had become 
thin and absolutely white. Soon after the commencement 
of treatment, the hair grew more luxuriantly and is being 
restored to its natural color (brown). 

491 



S p 



t h 



In another paiicnt, all the symptoms subsided in 
three weeks excepting the exophthalmos which was 
ameliorated about 50 per cent. The patient gained one- 
half pound a day for about three weeks. In both cases, 
the treatment was concussion of the 7th cervical spine. 

In some of the author's cases, patients who were 
apparently obese lost considerably in weight. This was 
probably due lo edema and myxedema complicating 
exophthalmic goitre and coincident with improvement 
of the latter, myxedema and edema disappeared. 



Among lettei^ received from physicians, one question i! 
paramount: "Will concussion cure simple forms of goitre?" 
The reply to this question may be as follows: The greater 
the vascularity of the gland (soft and tender, systolic blowing), 
the greater is the chance for its reduction. When much 
fibrous tissue has developed no results can be expected. 

Treatment by concussion is so simple that it should at 
least be given a trial. 

Very often a goitre is a true hypertrophy occurring in 
response for an augmented supply of secretion. Here, the 
use of thyroid extract will cause a reduction in the size of the 
gland. 

Emaciation.^ In some individuals despite careful exai 
ination, one cannot account for their poor nutrition. Weij 
Mitchell, and later, Playfair, demonstrated the great value of 
forced alimentation in many neuroses. This mastcure or 
methodical overfeeding was used in combination with an 
absolute rest cure. As I take a retrospect of the cases thus 
treated and of my success and failures, I now believe that 
I was unconsciously treating thyroid glands in a condition 
of hypersecretion, In a rest cure one executes all the methods 
necessary to depress the functions of the gland, viz.: rest, 
seclusion, quiet, an absence of genital irritation and sexi 
492 






Exophthalmic Goitre 



z. 





3. 





6- 





7- 
8' 




Fig. 117. — Case of Exophthalmic goitre made up of the following tetrad: 
tachycardia, exophthalmos, tremor and pulsating thyroid gland, i. — Sphygmo- 
gram of pulsating stnmia before commencing treatment (the record shows tachy- 
cardia and irregularity of pulsations) ; 2. — ^Tracing of gland after 5 minutes appli- 
cation of the rapid sinusoidal current in the region of the 7th cervical spine. 3. — 
Tracing of tremor before treatment; 4. — Tracing of tremor after sinusoidalization 
in the region of the 7th cervical spine; 5 and 6. — Cardiogram and pneumogram 
before, and 7 and 8, the same after conctission of the 7th cervical spine. Respiratory 
ataxia (page 85) is a not infrequent sign (according to the observations of the 
author) in this disease. This patient's heart became absolutely normal in rhythm 
after 3 treatments of concussion to the seventh cervical spine although this irre- 
gularity had existed since the inception of her disease 15 years before. 



493 



S p 



t h 



P y 



excitement and a diet of milk and farinaceous foods with a 
minimum of meat. 

Many of my cases in women suffered from relapses and ' 
not infrequently three rest cures were given in a single year, 
Some of these cases showing reduced vagus-tonus, have 
since then been treated successfully by concussion of the 7th 
cervical spine or by paravertebral pressure. Improvement 
is associated with an increase in weight without any change ( 
in the diet. Treatment at my office was supplemented by 
contraction of the cervical muscles {page 228) or by paraver- 
tebral pressure corresponding to the 7th cervical spine (page 
467)1 three or four times a day for one minute each time. 

Bronchial Asthma. — Reference has already been made 
to this subject on page 303, with supplementary observations 
on page 456. This disease is practically always associated 
with vagus-hypertonia. Even in the norm, if an assistant 
maintains firm pressure at the 7th cervical spine with the 
instrument shown in Fig. 112, within thirty seconds to two 
minutes, one can auscultate rOles peculiar to asthma In 
asthmatics or in cases of vagus-hypertonia, less pressure or a 
shorter interval of time is necessary to create rdles. 

Asthmatic paroxysms may be arrested by firm pressure 
with the thumbs in the absence of an instrument on both 
sides of the column between the third and fourth dorsal 
spines. 

The foregoing facts are of great importance in pulmonary 1 
auscultation. Many adventitious sounds are due either to 
increased or diminished vagus-tonus and by availing our- 
selves of the maneuvers suggested, one may avoid errors in 
diagnosis. 

Boeri**, found that when no abnormal breath-sou] 
were heard over the apex m incipient phthisis, they I 
audible after a few minutes deep massage over the a 
494 



Bronchial Asthma 

m 

the lung. The phenomenon in question is probably due to 
an augmentation of tone of the vagus ensuing from massage. 
Stretching the neck (Fig. 65) several times in succession 
accomplishes the same object. 

Phthisis is a disease usually due to hypertonia, and one 
frequently finds it associated with bronchospasm,^ a condition 
not unlike asthma. If one makes pressure for about one 
minute between the third and fourth dorsal spines, the r6les 
peculiar to asthma or bronchospasm disappear. 

Respecting the treatment of asthma, my experience con- 
cerns itself chiefly with the method described on page 312. 
My more recent experience justifies me in saying that I be- 
lieve more expeditious results may he achieved by depressing 
vagus-tone and to attain this object it is suggested to employ 
sinusoidalization or concussion of the region for depressing 
the vagus and to supplement it by treatment at home, viz. : 
pressure three or four times a day for one minute at a point 
on either side of the column between the third and fourth 
dorsal spines. 

In my experience, paroxysmal dilatation of the thoracic 
aorta may simulate asthma. Here one finds by careful 
percussion an increase in the area of aortic dulness. Vagus- 
tone is diminished and not increased as in asthma. In such 
instances of pseudo-asthma ^ the treatment indicated is that 
for aneurysms. 

Emphysema. — ^Increased vagus-tonus is associated with 
this condition in a number of instances, notably in yoimg 
persons. We have already noted (page 296) how one may 
transitorily dissipate the disease by nasal cocainization. 
The methods employed for reducing vagus-tone should be 
given a trial. One must, however, carefully supervise the 
treatment to avoid the development of symptoms dependent 
on reduced vagus-tonus. 

495 



S p 



d y I 



t h 



a p y 



In some instances, diminished vagus-tone being present, 
the antithetic method of treatment is indicated. 

Cardiac Neuroses. — The pharmacolo^c diagnosis \ 
these affections has been discussed on page 454. They may be 
associated with increased or diminished vagus-tonus. 

Gastric Neuroses. — The vagus controls the tone, 
peristalsis and secretion of the stomach. When the tone c 
the nerve is pathologically increased the motor, sensory and 
secretory phenomena of the organ are accentuated and f 
expression to clinical pictures identified with the gastr 
neuroses. 

Esophagismus, may be attributed to the same cause and 
one may note its temporary evanescence by methods which 
reduce vagus-tone, viz.: paravertebral pressure or an \ 
dermatic injection of atropin. 

Intestinal Neuroses. — In the diagnosis of these affet 
tions one must remember that atropin inhibits and that" 
pilocarpin, intensifies intestinal peristalsis. The many 
affections identified with increased or diminished vagus-tone 
include diarrhea, constipation and membranous ententis.M 
The latter is probably a motor-secretory neurosis and is* 
favorably influenced by atropin. In individuals \vith this 
disease, the use of pilocarpin may precipitate a paroxysm. 

Disturbances of Vision.* — Vagus-tone is identified 
with hysterical and neurasthenic forms of amblyopia 1 
asthenopia. 

The former refers to reduced visual acuity, contractiffl 
of the field of vision and the field for colors. 

The diagnosis of hysterical amblyopia is established 1 
the absence of demonstrable ocular changes, exhaustion of 
the visual field during examination and by the fact that the 

•A preliminary rending of the subjecl- mailer on page 441, wili aid in 
understanding oC this caplkui. 



As then op i a 

contraction of the field for colors is reversed (limits for red 
wider than those for blue.) 

The oculist observes that the acuity of vision and the 
extent of the visual field varies with the amelioration or 
aggravation of the health of the patient. 

That this form of amblyopia is a matter of vagus-tone 
I have demonstrated as follows: In a normal subject, 
determine with a perimeter the extent of the normal field of 
vision and the field for colors. Then, during the time the 
vagus-tone is depressed by an assistant (pressure between the 
third and fourth dorsal spines), again determine the fields. 
One notes that the visual field is contracted and the field for 
colors reversed. Pressure at the 7th cervical spine will in- 
crease the extent of both fields. 

In asthenopia^ despite good visual power, the eye becomes 
incapacitated for continuous exertion and the patient com- 
plains of pains in or above the eyes, frontal or occipital 
headaches, neuralgia, lacrymation and burning sensation in 
the lids, blurring of near vision and a host of other symptoms. 

The foregoing signs are always accentuated with arti- 
ficial illumination, after reading, writing, sewing and other 
forms of near application and in disturbances of the general 
health. Even in the norm, one may provoke asthenopic 
symptoms by reducing vagus-tone (pressure between the 
third and fourth dorsal spines), during the time patient is 
requested to read. Each eye may be separately tested. 
Pressure at the seventh cervical spine will improve acuity of 
vision and in asthenopia, vision previously blurred, becomes 
sharp and defined. 

The maneuvers suggested do not modify the vision of an 
astigmatic, myopic or hypermetropic eye. 

We have already demonstrated (page 443), that eye-strain 
is equivalent to vagus-stimulation and will evoke the vagal- 

497 



S p n d y I 



t h 



reflexes. If, however, one cocainizes the eyes with a 5 per 
cent, solution in a normal suhject, the vagal reflexes cannot 
be obtained. Paradoxical as it may appear, the reflexes 
continue despite the use of homatropin or atropin. 

The foregoing facts are in defiance of current opinion 
insomuch as atropin as a cycloplegic, by paralyzing accom- 
modation, is supposed to annihilate the majority of ocular 
reflexes. I have, however, made repeated tests in this respect 
and the results have been practically uniform. 

The preceding facts furnish an important guide in treal 
ment. Many patients with amblyopia and asthenopia suffei 
for yeare and arc incapacitated for serious occupation. 
Glasses often give no relief and stimulation by strychnin 
and electricity are the usual remedies. 

Concussion or sinusoidalization of the seventh cervical 
spine to increase vagus-tone, and supplementing this method 
by home-treatment (paravertebral pressure or extension of 
the muscles of the neck), may rescue some patients from 
hopeless invalidism. 

In rarer instances, spasm of accommodation (asthenopic 
symptoms and diminished acuteness of vision), may necessi- 
tate depression of vagus-tone (pressure between the thirdj 
and fourth dorsal vertebrae or concussion of the latter). 

Dr, B. L. Baker, of Seattle, referring to a patient with 
intriiclable symptoms in whom sinusoidalization (elec- 
trodes on either side of the 7th cervical spine) was em- 
ployed, observes as follows: "Abnormal sensations of 
long standing were removed and she was able to be fitted 
with glasses in a very satisfactory way. Perfectly so in 
her left eye which we were never able to do. The eyes 
when turned in any direction caused intense pain and 
nausea but the latter symptoms have disappeared." 

Disturbances of hearing. — I bchevc that the sense of 
498 



ct 



Auditory N e r v e 

audition is under the control of the autonomic nervous 
system. 

The following simple experiment will show how audition 
may be improved or diminished; determine with a normal 
subject the distance at which the tick of a watch is heard in 
the ear under examination. If an assistant now presses the 
seventh cervical spine with an instrument (Fig. 112) to in- 
crease vagus-tone, the patient perceives the tick at a greater 
distance. If pressure is now made between the third and 
fourth dorsal spines, to diminish vagus-tone, the tick is heard 
with less intensity and at a diminished distance. Hearing in 
the norm may be made more acute after concussion of the 
seventh cervical spine or after exercises which embrace 
extension of the head (page 228). More accurate quantitative 
tests may be made with Politzer's acoumeter. 

The auditory nerve consists of the cochlear and vesti- 
bular roots. The former is concerned in hearing and the 
latter in the maintenance of equilibrium. Hyperesthesia 
and irritation of the nerve may be manifested by hyper- 
acusis (sounds heard with disagreeable intensity), 
dysacusis (sounds cause unpleasant sensations), or as 
tinnitus aurium (subjective sounds). Another symptom 
of irritation may be dizziness somewhat like Meniere's 
disease. Diminished function or nervous deafness is not 
infrequent in hysteria and bone conduction is impaired 
or lost. 

Neurasthenia and hysteria are the most frequent 
functional nervous affections which exert the most pro- 
nounced effect upon the organ of hearing. With the 
tests cited, one may facilitate diagnosis. The specialist 
does not hope to modify these functional symptoms 
without treating the conditions which cause them. 
However, one must not forget that they may be signs of a 
local vagus-hypotonia or hypertonia, (page 452), and may 
be modified or cured by treating the irritative (reducing 

499 



S p on d y I o t h e r a p y 

vagus-tone) or paralytic symptoms (increasing vagus- 
tone). 

The sense of smeU may also be modified according to 
the methods cited for increasing or decreasing the sense 
of hearing. 

One may continue to dangerous extremes in the dis- 
cussion of this subject. The author has limited himself 
to a consideration of questions which he has amply veri- 
fied by clinical results and he has attempted to show the 
necessity for testing vagus-tone as a routine measure in 
* clinical practice with the. hope that it may lead to a bet- 
terment of our nosology. In diagnosis, diminished or in- 
creased vagus-tone may modify symptoms, and I shall 
show how one may create at will certain cardiac mur- 
murs and how they may be made to disappear (page 525). 
The creation of adventitious respiratory sounds has been 
already discussed (page 494). 

Phylogenetic Diseases. 

The term phylogenesis, refers to the evolution of a group 
or species of animals or plants from the simplest form. For 
a like reason, I employ this designation in accordance with 
my concept that many diseases and symptoms owe their 
origin to a primal basic anomaly. The preceding contra- 
venes the ontogenic conception of disease. 

Among the diseases in which I have established reduced 
vagus-tone are the following: 



I 
2 

3 
4 



Aortic dilatation. 

Aneurysm. 

Diabetes. 

Hyperthyroidism. 

Pertussis. 



A dilated aorta is probably one of the causes of dyspnea 
in exophthalmic goitre (page 488). In four of my cases, 

500 



Phylogenetic Diseases 

classic symptoms of aneurysm (thoracic) were associated 
with Basedow's disease. 

Glycosuria was found in several patients with aneurysm. 

A patient with an aneurysm of the thoracic aorta, 
referred to me by Dr. Hubert N. Rowell, of Berkeley and 
who was discharged as symptomatically cured after 
treatment lasting four weeks, returned after three years 
absolutely well respecting the aneurysm but with sym- 
toms of diabetes (3 per cent, of sugar despite the most 
rigid diet). Vagus-tone absent. Within three weeks 
after treatment (concussion of seventh cervical spine), 
the lower lung-border which did not descend at all when 
pressure was made at the 7th cervical spine-region, de- 
scended 3 cm., and sugar disappeared from the urine, 
notwithstanding the ingestion of the average carbo- 
hydrate consumption. At the time of writing, the patient 
is well. Before coming to my office the second time, the 
attention of the patient was called to his condition by 
polyuria and an intractable neuritis. The latter disap- 
peared with disappearance of sugar in the urine. 

It is easy to explain many anomalies of function by 
correctly assuming modifications in glandular activity. 
Thus, the amount of epinephrin produced and entering 
the circulation varies. This substance stimulates plain 
muscle and glandular cells which are functionally related 
to the sympathetic nerve-fibers. Its subcutaneous ad- 
ministration causes the appearance of dextrose in the 
urine and a condition of hyperglycemia. 

Exophthalmic goitre is coordinated with emaciation and 
occasionally, with polyuria, glycosuria and true diabetes. 

Pertussis is associated with aortic dilatation(Chapter XVII) 
and in both affections the vagus- tonus is reduced. Some 
infectious diseases reduce vagus-tone and they may be recog- 
nized as etiologic factors in Basedow's disease and aneurysm 
(syphilis). 

501 



S p n d y I 



t h 



a p y 



A neurotic temperament (reduced vagus-tone) is a domi- 
nant etiologic factor in diabetes. One notes the occurrence i 
of the same or liiie diseases in one family or between man \ 
and wife, maladies which I have called diseases of prop- 
inquity. Contagious influences like tuberculosis are not in- 
cluded in this category. Thus, Schmidt observed among 
2320 diabetics, twenty-six cases in which the disease occurred 1 
concurrently in man and wife. 

It is questionable concerning the role played by food in ' 
the etiology of reduced vagus-tone, although my limited 
observations show that an exclusive diet of proteid food has | 
a marked influence in reducing vagus-tone. 

I recently saw two sisters in consultation with Dr. L. 
Boyd, of Long Beach, one of whom had diabetes, and the -j 
other an aneurysm of the thoracic aorta. 

Among the diseases in which there Is increased vagus- j 
tone are: 

Bronchial asthma. 

Emphysema. 

Tuberculosis. 

Gastric and Intestinal Neuroses. 

Emphysema is almost invariably associated with phthisis 
and asthma. In my clientele, I have frequently noted pul- 
monary tuberculosis following asthma and observed that the 
cough and paroxysmal dyspnea of the latter affection were 
often caused by bronchospasm. Asthma often runs in 
families with irritable nervous systems and the reflex causes 
which provoke attacks also augment vagus-tonus. 

Many gastric and intestinal neuroses are associated with 
symptoms of cardiac disease suggestive of vagus-hypertonia. 

Enuresis, was frequently observed by the author in 
asthmatic children and reduction in the tone of the vagus 

502 



Reflex S y m p t 



m 



was productive of good results. The mother was in- 
instructed to make pressure several times a day on either 
side of the spine between the 3d and 4th dorsal vertebrae 
to reduce vagus-tone. 

Dr. L. Boyd reports the case of a yoimg man of 20 
years, with enuresis since birth. Treatment had been 
tried without results. Concussion of the fifth lumbar 
vertebra to provoke the bladder reflex (page 358) yielded 
excellent results. 

A placebo was given to the patient. The author finds 
it absolutely necessary with some patients to employ an 
indifferent drug in association with treatment. Some 
patients are obsessed with the conviction that drugs are 
iht Jons et origo of medical practice and they will con- 
tinue no treatment in which drugs are excluded. 

"It is quite as important to know what kind of a 
patient the disease has got, as to know what kind of a 
disease the patient has got." 

"The patient wishes not only to be cured, but to be 
treated; his luxury is the importance of the physician 
and his remedies." 

Reflex symptoms may so mask the primiary disease that 
the latter is disregarded. Reduced tone of the vagus is 
associated with dilatation of the heart and the symptoms may 
be essentially abdominal owing to the rapid distension of the 
liver and the paralytic inflation of the stomach and intestines. 

The attacks in some forms of angina pectoris and 
certain neuroses terminate with eructations of gas and 
the discharge of a large quantity of clear urine. 

What probably occurs is as follows: The increased 
vagus-tonus closes the cardiac or pyloric orifice of the 
stomach and when the tone of the vagus is reduced, the 
orificial spasm of the stomach yields, permiting eructa- 
tion of the incarcerated gas. 

I have seen two cases of aneurysm of the abdominal 
aorta in which there were only thoradc symptoms. 

503 



S p 



d y I 



a p y\ 



The crises of tabes are caused by autonomic irritation 
as evidenced by pupillary contraction, increased secre- 
tion and peristalsis of the stomach and intestines. In 
the later stages of the disease, the hypertonic are suc- 
ceeded by hypotonic signs. One knows that in (afiej, 
anatomic lesions of the vagus may be demonstrated. 

Vagal Hyperesthesia. — In diseases caused by vagus-" 
hypertonia, the vagus in the neck is extremely sensative to 
pressure, whereas in diseases caused by vagus-hypotonia, 
paravertebral areas of tenderness may be detected between. 
the third and fourth dorsal spines. 

The sensitiveness in question disappears pari passu with ' 
the disappearance of the disease. The dorsal areas become 
less sensitive at once by concussion of the 7th cervical spine 
(which increases vagus-tone) and the vagus in the neck, byj 
concussion of the third and fourth dorsal spines (which c 
creases vagus-tone). 

Clinical Pharmacology. 

The scientific study of pharmacology should not 
limited to laboratory-animals, on the contrary, the humanj 
offers a fruitful field for investigation (z'ide, page 270). The 
author has investigated many drugs and concludes that a 
large number owe their physiologic and toxic action to their 
influence on vagus-tone. Only a few drugs will be cited, 
insomuch as the scope of this work precludes any extended 
reference to this subject. The author suggests, however, 
that it may serve as an index for research work along new] 
and original hues. 

Many drugs, according to their action, may be divided^ 
into two classes: 

1. Drugs which increase vagus-tone; 

2, Drugs which. diminish vagus-tone. 



Clinical Pharmacology 

Their action may be manifested directly or indirectly. 
Thus adrenalin acting exclusively on the sympathetic-fibers 
by stimulation, depresses the vagus-fibers and therefore indi- 
rectly diminishes vagus-tone (page 453). 

Method of Investigation. — ^As we have already shown 
(page 469), paravertebral pressure at the 7th cervical spine 
increases vagus-tone and among other effects it causes the 
lower-lung border to descend. The degree and duration of 
descent are accepted as criteria of vagus-tone. The lower 
lung-border posteriorly is first determined, after which 
pressure is made opposite the 7th cervical spine for 30 seconds 
and the lower border is again ascertained. Not only must 
we determine the degree of descent but its duration. 

Drugs which act by increasing vagus-tone cause a descent 
of from 4 to 6 cm., and this descent is maintained from one 
to ten or more minutes. Drugs which diminish vagus-tone 
cause little or no descent of the lung and if the latter does 
descend, its descent is brief. Many drugs show a primary 
stimulation of vagus-tone followed by depression of the latter. 
Powerful vago-tonic drugs cause a descent of the lung-border 
without previous pressure at the 7th cervical spine. 

Reference has been made to some drugs investigated by • 
the author. Among other drugs may be mentioned: 

QuiNiN. — This drug has a powerful action in increasing 
the tone of the vagus. 

It is now possible to comprehend many therapeutic facts 
heretofore inexplicable. 

Exophthalmic goitre is due to diminished vagus-tone 
(page 484). Now, among the most satisfactory drugs for 
influencing the latter disease is quinin hydrobromid in 
capsules containing 5 grains each, to the limit of the 
patient's tolerance. Toxicity is shown by the appearance 
of tinnitus, when the use of the drug must be suspended 

505 



Spondyloth 



temporarily. The drug must be taken for months or 
years. In a study of 56 cases thus treated by Jackson", 
76 per cent, had no signs or symptoms for two years, 
while 13 per cent, had been benefited, and only 6 cases 
(ii per cent.) could be considered failures. Within two 
weeks after taking this drug, improvement was noted by 
diminution of the palpitation, sweating, tremor and 
other nervous symptoms. In many cases the thyroid 
diminished in size, but the exophthalmos was the last sign 
to disappear (a or 3 years) or it persisted with the tremor. 

Malaeia. — A typic paroxysm of this disease may be pre- 1 
cipitated by eliciting the splenic reflex of contraction (page ' 
355). I saw a case of latent malaria with Dr. R. Bine, m 
which a typic paroxysm was precipitated on the day following 
the elicitation of the reflex. 

We speak of quinin as the most effective parasiticide 
in thb disease and there is ample reason to justify such a 
conclusion but in this action, we dare not ignore the 
bactericidal power of the blood owing to the protective 
substances or by anaphylaxis. Italian observers claim 
that the present drug -treatment of malaria is unable 
to free the system completely of the malarial parasites. 
As long as the spleen is enlarged the disease cannot be 
regarded as cured, A single hypodermatic injection of 
15 grains of quinin and urea hydrochlorid will, in ma- 
laria, cause a "freedom period" lasting either b\ or 13 
days (S, Solis Cohen). -^ small dose (0.3 to 1 gram, at 
intervals of 3 days to one week — about half a dozen 
injections), will often enable one to demonstrate Plas- 
modia in the peripheral blood although previously absent 
(Billings). 

Now, the action of quinin is to increase vagus-tone 
and, by so doing, to contract the spleen. Slrychnin, is 
likewise a vagus-tonic and within one hour after an hypo- 
dermatic injection of a therapeutic dose, the plasmodia of 
malaria may be demonstrated in the peripheral blood 
although previously absent. 

506 



Clinical Pharmacology 

Quinin is efFective in enlargement of the spleen from 
any cause simply because it contracts the organ by 
stimulation of the vagus. 

Perhaps the time will yet arrive when we shall gauge 
the value of drugs in malaria according to their action 
on the vagus and that pilocarpin or other efficient vagal 
exdtant may be used to the exclusion of quinin. 

In a case of splenic leucocythemia, I could always 
produce an enormous increase of leucocytes in the blood 
immediately after the elicitation of the splenic reflex of 
contraction. 

Leucocytosis, following the hypodermic injection of 
pilocarpin, is essentially mechanic and due as Henwood, 
of Toronto, suggests to contraction of the muscle-element 
in the spleen and lymph-glands. 

Diabetes. — Magyary-Kossa^extols theinhalation of 
carbon dioxid to reduce glycosuria. In diabetes, dimin- 
ished vagus-tone can be demonstrated (page 479)1 ^^^ 
carbon dioxid is a vagal-excitant. 

Suspension of respiration for 30 seconds or longer 
increases vagus-tone. 

Our present conception of shock is not attributed 
to vasomotor failure, but to acapnia (diminished carbon 
dioxid in the blood). Stimulation of the respiratory 
center depends upon carbon dioxid alone, oxygen play- 
ing a passive part. 

No one drug in diabetes seems to have a curative 
influence. 

Arsenic may act by increasing vagus-tone, and opium, 
bromids and antip3rrin probably achieve their action by 
subduing the neurotic element in this disease. 

Antipyrin primarily excites the vagus for about 5 
minutes and is then followed by powerful depression of 
the nerve. 

The iodids, chloroform and ether, diminish vagus- 
tone. The latter act as evanescent vagal-irritants, but 
there is a marked secondary depression of tone. 

Potassium iodid often acts as a specific in asthma 

507 



Spondylotherapy 

and this is probably attained by diminishing vagus-tone, 
which in asthma is increased. Fowler* s solution often 
• prevents iodism, iodin diminishes and arsenic increases 
vagus-tone. 

Potassium iodid is used empirically in aneurysms. 
The effects are probably attained by diminishing blood- 
pressure, for by diminishing vagus-tone, the aneurysm 
dilates. It may be that the latter is less than the re- 
duction in pressure, otherwise the drug would do more 
harm than good. 

Nasal cocainization elicits an immediate depression 
of vagus-tone, whereas the inhalation of ammonia^ 
increases the tone. 

Amyl nitrite inhalation increases vagus-tone. This 
drug, in my experience, is only efficient in the cardiec- 
tatic forms of angina pectoris due to diminished vagus- 
tone (page 543). 

Sodium cacodylate and mercury are powerful tonics 
of the vagus. The latter observations invite theorization, 
which will however be curtailed. The present treatment 
of syphilis with salvarsan is chemo-therapeutic, and by 
the method of ^Hherapia sterilisans magna" the action of 
the drug is parasitotropic. 

In syphilis, I have found diminished tone of the 
vagus and it is not improbable that remedies in this 
disease (excepting the iodid), by increasing the tone of 
the vagus accomplish another object as yet not definitely 
known. 

Reliable preparations of digitalis and strophanthin 
given hypoderraatically increase the tone of the vagus. 
Within 15 minutes, the lung-border may be made to 
descend double the distance that it did prior to the in- 
jection. After this manner, the author tests the relia- 
bility of these drugs which are notoriously unreliable. 
A normal subject is used for experimental purposes. 
In the same way, one can predict the action of the drugs 
on patients. 

508 



Recapitulation 



Recapitulation. 

The vagal and sympathetic fibers in the norm are in 
physiologic antagonism. The ideal vagal-stimulant is pilo- 
carpin, and the ideal sympathetic-stimulant is adrenalin. 
Atropin diminishes vagus-tone by paralyzing the motor end- 
ings of the vagus. Thyroid diminishes vagus-tone. 

Symptoms or diseases (asthma, angina pectoris), due to 
increased vagus-tone are acentuated by pilocarpin and 
ameliorated by adrenalin and atropin. 

The toxic action of some drugs may be inhibited by com- 
bining them with their physiologic antagonists. Thus quinin 
may be used with thyroid or pilocarpin with the iodids. 
However, this method is not scientific, for we are adminis- 
tering synchronously a drug with its antidote, an undesirable 
procedure when one desires to test adequately the physiologic 
action of a medicament. 

Therapeutically, we employ drugs which increase vagus- 
tone (pilocarpin) in diseases which demand them and con- 
versely, drugs which decrease vagus-tone (thyroid, iodids, 
adrenalin) are indicated. 



509 



Spondylotherapy 



CHAPTER XIV. 

FURTHER ADVANCES IN THE DIAGNOSIS AND TREATMENT OF 
DISEASES OF THE CIRCULATORY SYSTEM. 

TESTS FOR HEART — SUFFICIENCY — ^KUATSU — HEART-FAILURE — ^FUNC- 
TIONAL CARDIAC MURMURS — REFLEX OF THE PULMONARY ARTERY 
— INHIBITION OF THE HEART— CARDIOPTOSIS — SUBCLAVIAN MUR- 
MURS — ANGINA PECTORIS — ANGINOID PAINS — ^PHRENIC NERVE — 
DIAPHRAGM REFLEX — ^ANEURYSM — FLUOROSCOPY OF THE AORTA. 

TESTS FOR HEART-SUFFICIENCY.* 

In making a comparative estimate of different fimctional 
tests of cardiac efficiency, the author is constrained to con- 
clude that the test to be specified presently is the most re- 
liable. 

Numerous writers confirm the observation of de la Camp, 
viz., when the cardiac muscle is normal, exercise even carried 
to exhaustion and fainting does not produce dilatation of the 
ventricles. On the contrary, the heart diminishes in volume. 

In myocardial disease, even moderate exercise provokes 
ventricular dilatation. 

In other words, the diameters of the heart are maintained 
hy visceral-tone (page 451). One first determines the borders 
of the heart by percussion. The latter is facilitated by 
forcible extension of the neck during the time percussion is 
executed (page 228). Next the patient is directed to raise 
and lower the body a number of times (until slight dyspnea 
is produced), by flexing the knees. 

*Vide tests on page 21$ el seq. 

510 



e s t s f r Heart- S u ffi c i en c y 

If percussion (with neck extended), shows a diminished 
area of cardiac dulness, the myocardial tone is normal and 
the muscle is efficient, otherwise the tone is deficient and the 
muscle is inefficient. In percussion, reliance is only to be 
placed on the elicitation of the deep or relative dulness 
(forcible percussion). A method Original with the author for 
testing cardiac tone is described on page 471. 




— Ulmtrating Ihe author's method of threshold percussion, 



The modified threshold pereussion of the author is 
available for defining the borders of the viscera. Per- 
cussion is executed in the mid -respiratory position. 
The lip of the index finger of one hand is firmly fixed in 
an intercostal space al an angle with the chest-wall, but 
parallel with the boundary that is to be percussed. 
As the fmger gradually approaches the boundary, it is 
struck with the middle finger of ihe other hand at its 
base and side, as indicated by the black spot in fig. 118. 

Continental writers, notably Zulawski", and Merklen and 
Heitz", find that when the liearl reflex (page 199), can be 
elicited in myocardial weakness, it indicates a favorable 
SU 



n d y I 



a p y 



prognosis. The former finds that the reflex (by irritating,- 
the skin of the precordial region), in the norm reduces t 
dulness of the heart from i to rj cm., and the latter shond 
that, in cardiectasis, the reflex may persist for several hours.4 

My results are not in accord with the latter observa- 
tions; it is the duration and not the presence of the reflex 
which counts. In the norm, the reflex lasts from one-half 
to three minutes; in myocardial disease, it may persist for 
hours. In the latter instance, this heart reflex of degen- 
eration corresponds with the reaction of degeneration, 
viz., a muscular contraction which is tardy and persistent. 

Myocardial disease may be suspected even in the ab- 
sence of cardiac signs, when symptoms not unlike those 
which accompany the broken compensation of valvular 
diseases present themselves. A reliable preparation of 
digitalis may solve the difficulty; if, after five days, the 
symptoms are not relieved and there is no rise of the 
peripheral arterial tension nor increased strength of the 
pulse, the drug can do no good and may even be danger- 
ous. Many preparations of digitalis are practically inert, 
and this fact may be demonstrated by its physiologic 
action. Within thirty-six hours after the use of a reliable 
preparation given in adequate doses, one finds that the 
pulse becomes stronger, more regular and slightly de- 
creased in frequency (provided the pulse was accelerated 
before the use of digitalis) and diuresis is augmented. 
By estimating the quantity of urine excreted one is af- 
forded a guide in a dual direction: the reliability of the 
drug and the efficiency of the cardiac muscle. In cardiac 
muscular insufficiency, the quantity of urine may be di- 
minished by one-half or more. Owing to the delayed 
action of digitalis, an increase in the quantity of urine 
does not occur until the second day of its use; then it 
continues to increase day after day until the normal is 



•The tomparalive results obtained from different 
relkx are shown on page 636. 



cibods for evoking the beait^ 



Tests for Heart-Suffictency 

attained (1500 c.c. in twenty-four hours in a healthy 
adult); at this time, and when the pulse frequency has 
been reduced and the tension is increased, one should 
withdraw the drug, reduce the dose, or give it less fre- 
quently. 

In using digitalis for diagnostic or therapeutic pur- 
poses, the writer first unloads the bowels and diminishes 
hepatic congestion with a few small doses of calomel. 
He gives a reliable /res/r infusion of digitalis in doses of 
4 fluid drachms combined with diuretin (sodio-theo- 
bromin salicylate). 

Diuretin is administered in doses of 15 grains; it is a 
powerful diuretic and antagonizes the vasoconstrictor 
components of digitalis. The more recent researches of 
Lowy seem to show that digitalis dilates the coronary 
and renal vessels. The latter pharmacologic observation, 
however, is not wholly in accord with the clinical results. 

It is often impossible to differentiate between a prim- 
ary myocarditis and a primary nephritis. 

If digitalis causes diuresis, one may conclude that the 
previous oliguria was caused by a failure in the circula- 
tory apparatus, because its effects are secured by its stim- 
ulating action on the heart and blood vessels. If drugs 
like theodn, diuretin and calomel are effective, we con- 
clude that the effects are attained by direct action on the 
renal epithelium. 

In the differential diagnosis of primary myocarditis 
and primary nephritis, Wintemitz has suggested the 
catalase test. In chronic nephritis, the catalase of the 
blood is destroyed, hence, when the latter is brought into 
contact with hydrogen peroxide, there is absolutely no 
liberation of oxygen whereas the blood of patients with 
heart enfeeblement splits peroxide. Others concede the 
importance of this test only in advanced cases of nephritis 
either in the uremic or preuremic states. 

The s3rmptoms of broken compensation from myocar- 
dial disease may be quickly differentiated from a host of 
other maladies by stimulation of the myocardium by con- 

513 



Spondylotherapy 

cussionof th€ seventh cervical spine. Even within a few min- 
utes after concussion is executed, cyanosis, dyspnea and 
other signs of an insufficient myocardiiun become less evi- 
dent or disappear for several hours and for a longer inter- 
val with repetition of the concussion. To the uninitiated, 
it is impossible to conceive the great possibilities of this 
very simple mechanical method of cardiac stimulation. 
The writer has seen several practically moribund patients 
with pnemnonia in whom the conventional cardiac stim- 
lants were employed without avail, yet these very pa- 
tients were not only revived but were revived quickly by 
the method in question. In myocardial disease, when it is 
a question of fortifying the jaded cardiac musculature, 
the writer no longer employs drugs but relies solely on 
concussion of the seventh cervical spine. When the latter 
fails, the cardiac musculature is no longer capable of res- 
titution. 

The real danger with concussion to elicit the heart reflex 
is its overuse conducing to exhaustion of the myocardium. 
Concussion should only be used once a day until there is a 
moderate restoratiofi of the myocardium and then twice or 
thrice weekly. 

This over-stimulation compromises the duration rather 
than the amplitude of the heart reflex. Thus, concussion of 
the 7th cervical spine for one minute gives a reflex with an 
amplitude of 1.6 cm., and a duration of 3 min. and 40 sec, 
whereas, concussion for 5 minutes yields a reflex with an 
amplitude of 2 cm., but lasting only two minutes. 

Recently, the writer saw a patient with apex pneu- 
monia in consultation with Dr. V. G. Vecki, of San Fran- 
cisco, the eminent genitourinary specialist. The patient 
was practically moribund. During the course of her 
disease, the conventional cardiac stimulants were em- 
ployed. Suddenly during the night, however, she be- 
came extremely cyanotic and pulseless and it was deter- 

514 



Tests for Heart-Sufficiency 

mined to concuss the seventh cervical spine to awaken, 
as it were, the enervated heart. No percussion appara- 
tus was at command and, in lieu of the latter, the palmar 
surfaces of the fingers were applied to the seventh cervi- 
cal spine, and, with the clenched fist, the dorsal surfaces 
of the fingers were struck a series of short and vigorous 
blows (Fig. 2). The latter method of concussion was 
continued for about ten minutes with intervals of rest. 
Soon after concussion was commenced, the cyanosis be- 
came less evident and the pulse was again perceptible. 
Every two hours during the night this method was con- 
tinued and thereafter at less frequent intervals until con- 
valescence was established. It was evident to the nurses 
and others that after each stance of the concussion treat- 
ment there was an immediate evanescence of the cyano- 
sis and the pulse always became stronger and less fre- 
quent. 

It is conceded that pneumonia is the most fatal of all 
acute diseases, tha* there exists no specific medication, and 
that the most important indication is to maintain the cir- 
culation. I am firmly convinced that the systematic exe- 
cution of the method cited will prove of material aid in 
hastening recovery from this dread disease, which other- 
wise may prove fatal. 

An efficient percussion apparatus should be at the 
physician's command in all acute diseases and, as Dr. 
Vecki5>3 suggests, after operations when there is any dan- 
ger of cardiac implication. I must emphasize, however, 
the necessity of a suitable apparatus. The latter must 
give a percussion stroke. AU other motions, such as os- 
cillations, shaking, and friction, yield absolutely no re- 
sults. 

In a recent contribution^, the author has described 
Kuatsu or the Japanese method of restoring life. 

Kuatsu, or the restoration of life, is an integral part of 
jiu jitsu. The latter is usually regarded wholly as a 
means of physical training and as a method of combat, 
but when the victim is ''knocked out,'' recourse is had 

515 



Spondylotherapy 



B 



by adepts to definite methods of resuscitation known as 
kuatsu. 

Many centuries ago, when jiu jitsu was primarily con- 
ceived in Japan, kuatsu was used for reviving individuals 
who were rendered unconscious by the various systems 
of jiu jitsu, but later it was shown that kuatsu was 
equally effective in instances of sunstroke, drowning, and 
injuries from other causes. 

It is stated that the adept in jiu jitsu inflicts no injury 
that cannot be prompdy remedied by the aid of kuatsu, 
whereas our pugilists may inflict blows which may render 
their opponents unconscious and yet are unable to do any- 
thing to revive them. The captious critics of kuatsu 
seek to dispose of the supposed exaggerated claims of the 
latter by the derisive observation that the jiu jitsu man 
is able to restore those whom he kills. 

The line of demarcation between life and death is 
difficult of determination and an individual should, para- 
doxical as it may appear, only be regarded as dead when 
it is demonstrated that he is not alive. The extraordinary 
tenacity of life shown by the exsected heart is really mar- 
velous. By artificial perfusion Kuliabko elicited well 
marked contractions of the entire heart of the rabbit five 
days after the death of the animal, and the same author- 
ity completely revived the heart of a four year old boy 
who had died of pneumonia twenty-four hours after 
death. 

A study of the charts in any representative work* on 
jiu jitsu shows a number of points on the body surface 
which, when struck, will cause either insensibility or 
death. The writer has exerted firm pressure over the 
various points in question and noted that in the majority 
of instances there was a reflex inhibition of the heart dur- 
ing the period of pressure. The latter effects were more 
evident when the sphygmograph was employed. The 



♦A representative work of this character is that of Hancock, The Compete Kano 
Jiu- Jitsu, There are many systems of jiu-jitsu in Japan, but the Kano system 
has been adopted by the government. 

516 



Tests for H e art - S uffic ten c y 

writer has demonstrated elsewhere, however, that the 
heart may be inhibited reflexly practicaUy anywhere on 
the body surface, but that the definite points of election 
are the intercostal spaces, the abdomen, the muscles of the 
neck, and the region on either side of the spine corres- 
sponding to the upper dorsal vertebrae. Irritation of the 
mucosa of the stomach, nose, and rectum is equally ef- 
fective in inhibiting the heart, but, if the mucous mem- 
branes in question have been previously cocainized, such 
inhibition does not ensue. 

Inhibition of the organ in the foregoing instances, 
is effected by reflex sensory impulses acting on the vagus, 
the inhibitory nerve of the heart. The action of atropin 
and pilocarpin on the heart reflex has been considered 
on page 454. In kuatsu, the subject is placed in the 
prone posture with arms extended sideways and the 
operator with his wrist lands severely upon the seventh 
cervical vertebra with the regularity of a carpenter strik- 
ing with a hammer. As soon as the patient recovers con- 
sciousness, he is placed in a sitting posture, his arms are 
rotated, and he is aided in walking. The latter injunc- 
tion is regarded as mandatory in the application of 
kuatsu, the object being to completely restore the func- 
tions of the circulation and respiration, otherwise, it 
is said the patient relapses into unconsciousness.* 

The resistance of the myocardium in stretching during 
diastole represents the tonicity of the cardiac muscle. 
In the normal state stretching of the cardiac parietes is 
effected by the pressure of the blood which enters the 
heart from the large veins and is essentially a venous 
pressure. It follows that in high venous pressure, pro- 
vided the cardiac tonicity is compromised, a cardiac 
dilatation must ensue. In the latter condition the amount 
of residual blood in the heart usually exceeds the systolic 
output of the organ. 

*The minute details of the method are not recounted although regarded as im- 
portant by authors on the subject. In the opinion of the writer, the essential 
feature of the method is concussion of the seventh cervical s^nne. 

517 



Spondyloth e r a p y 

In the vagus of the frog there is one set of fibres which 
only inQuences the heart rate (chronotropic effects), 
whereas another set increases the force of the contraction 
and cardiac tonicity without affecting the rate. The 
latter tonic fibres in the vagus are stimulated by the usual 
cardiotonics, but the action of the latter is inhibited if 
the vagi have been cut or paralyzed by atropin. The 
action of the cardiac nerves has always been a subject of 
contention. 

The vagus slows the action of the heart (inhibitory ac- 
tion), whereas the accelerator nerves quicken the action 
of the heart. Both nerves in the norm are in tonic activ- 
ity. 

Reference to Fig. 119, shows the origin and course of the 
cardiac nerves. It will be noted that the spinous process of 
the 7th cervical vertebra corresponds to the 3d dorsal seg- 
ment of the cord, which in turn corresponds to the root- 
origin of the third thoracic nerve. 

Concussion is often a more powerful nerve stimulant than 
electricity and a blow on the head results in photopsia due to 
stimulation of the optic nerve by the propagated blow. 

In concussion of the 7th cervical spine, the blow is trans- 
mitted through the spinal ner\'es to the sympathetic ganglia 
which form in connection with branches of the vagus, the 
superficial and deep cardiac plexus, and it is essentially by 
this indirect stimulation of the vagus that the effects are 
attained by concussion of the 7th cervical spine. 

Aortic contraction in aneurysms is effected through the 
same neuro-medullary pathway. 

The writer has shown empirically that the best site 
for stimulating the vagus and thus increasing the force of 
cardiac contraction and cardiac tonicity is the spinous 
process of the seventh cervical spine. The most effective 
excitant of the heart reflex is concussion, which is a me- 

518 



Heart R efle x of Dilatation 

chauical stimulus and that the reflex in question may be 
elicited with the same certainty and precisian as are the 
reflexes by the vivisectionist in his laboratory. 
~ A just appreciation of the latter facts by the clinician 
will prove of great value to him in the treatment of myo- 
cardial insufficiency and as an aid in resuscitation. They 
also explain the kuatsu method of reanimation. 

In conclusion, I may say for academic purposes only 
that the heart letlex cited is the heart redex o( contraction. 
The counter reflex of dilation, has been described on page 




Fig. 119. — Origin and course of the cardiac nen'es.— Moi, Sens, nuclei of the 
efferenl {motor) and afferent (sensory) fibers of the vagus C, 1, 3, 3, 4, 5, 6, 7, 8, 
and T, i to 8, cervical and thoracic (dorsal) spinal nerves. 'SCG, MCG, ICG, 
superior, middle and inferior cervical ganglia. REC LAR, recurrent laryngeal 
nerve; CPL, cardiac plexus. T, 3 (inclosed in a circle), corresponds to the spinous 
pnxessof the seventh cervical vertebra (from Powell and Git>son, slightly modified) . 



TeE Heart Reflex of Dilatation, elicited by con- 
cussion the last four dorsal vertebra (concussion of the 
loth dorsal spine suffices), is a dilatation of accommoda- 

519 



Spondyloth 



lion, owing to an increased vtilume of blood provoked by 
such concussion (page 617]. Concussion of the third and 
fourth dorsal spines, or pressure between the latter, re- 
duces vagus- tone {page 472), and eventuates in an active 
dilalation. The heart reflex of dilatation is of little value 
in practice excepting when the heart is undersized (hypo- 
plasia) in phthisis, advanced valvular disease (specially 
the left ventricle in mitral stenosis) and in old age (senile 
heart). Concussion of the loth dorsal spine should be 
executed to achieve our object. 

When rapidity 0/ action from drugs is desirable in diag- 
nostic-therapeutics, much may be expected from the in- 
travenous employment* of xlrophanlhin. Thus adminis- 
tered, its action it fully manifested within sixty minutes. 
Administered by the mouth, its action is not evident for 
at least seventeen hours. When it is remembered thai the 
physiologic action of digitalis is not manifested Cor at 
least thirty-six hours, it is not difficult to note the many 
advantages accruing from the intravenous employment 
of strophanthin. A single injection of the latter drug 
is capable of fully restoring a patient with cardiac incom- 
petency. The dose of strophanthin (a reliable prepara- 
tion is that of Thomas) is from i to i mg. (gr. 1-240 to 
i-iao). It is also procurable in sterile \'ials. 

In suspected myocardial disease due to lues, a po^tive 
Wassermann reaction may prove as valuable as the same 
reaction in the diagnosis of luetic aortic insufficiency and 
the subsequent therapeutic results with mercury and 
potassium iodide will clinch the diagnosis. 

To appreciate the diagnostic-therapeutic value of digi- 
talis, one must recognize its action which may be divided 
into two periods: (i) therapeutic stadium, in which the 
cardiac force is increased; (2) toxic stadium, when such 



•To make an intravenous injetlion, dilate veins of arm with a rubber band a 
the elbow. Partially fill syringe (free o( air-bubbles) with the solution a 
then insert needle into the median vein. Before injecting, some blood is drairi 
into the syringe to be sure that the needle is in the vein. Then, the rubber b. 
Is leraoved and the contents of the sjringe emptied. 



520 



The Heart and Its Innervation 

force is diminished. In the first stadium, slowing of the 
pulse is slight, whereas in the second stadiimi, it is very 
much diminished in frequency, and may even become 
arrhythmic. This excessive slowing of the pulse may be 
accepted as the primary signal of the toxic action of digi- 
talis. The chief effects of digitalis are exerted on the 
heart muscle, and the greater the integrity of this muscle, 
the better the action of this drug on the heart; hence such 
reaction may be accepted as a diagnostic indication of 
the condition of the cardiac muscle. Thus, the more in- 
tense the myocardial degeneration, the more susceptible 
is the reaction to small quantities of digitalis. If, instead 
of securing the physiologic action of digitalis, toxic effects 
are observed, one would conclude that the myocardial 
changes were pronounced. In such instances, the use of 
digitalis is positively dangerous. 

The author desires to emphasize the fact that (here are 
neither exclusive nor specific methods in therapeutics but that 
the synergistic actiofi of different remedies must be conciliated. 

In awakening the tonicity of an enervated heart, the use 
of digitalis with diuretin (page 513), may be indicated in 
association with concussion of the 7th cervical spine when 
the heart fails to respond to the latter method alone. Con- 
cussion is essentially a stimulant to the vagus-fibers which 
increase the contractility (inotropic) of the myocardium and 
may be without action on the rhythmicity (chronotropic 
influence), hence the value of digitalis, which brings about 
slowing of the heart. 

Having achieved our object with the combined digitalis- 
diuretin prescription, one may dispense with the latter and 
employ concussion exclusively. 

The Heart and Its Innervation. — ^A thorough 
understanding of this subject has an important influence 
on our therapeutic efforts. In addition to the vagus 
nerve, the action of which has already been studied, there 

521 



Spondyloth e r a p y 

are motor fibers from the S3rmpathetic system, known as 
the acctleraior nerve of the heart (Fig. 113). Stimulation 
of the latter, causes an increase in the rate of beat of the 
heart, but not infrequently the force or energy of the beat 
may be increased and the rate may remain unaffected. 
In consequence of the latter effects, physiologists assume 
that, the accelerator nerve contains fibers which acceler- 
ate the rate, and others (augmentors), which cause a 
more forcible beat. Hering has shown that stimulation 
of the accelerators may revive a heart that has ceased to 
beat. The vagi and accelerators are normally in tonic 
activity. Now, cardiac vigor is not only a muscular but 
a neuro-muscular question. While muscular tone, as a 
rule, is secured by vagus-stimulation (the after-effects 
on this inhibitory nerve being to increase the force of the 
beat), we have in our discussion ignored the influence of 
the accelerator nerve. Both nerves are in physiologic 
antagonism. In a given case of cardiac-insufficiency, it is 
wise to test the tone of the sympathetic and vagus-fibers 
according to the methods described on pages 469 and 472, 
to determine whether our therapy should be sympathico- 
tropic or vagotropic (page 451). In addition to these 
tests, one may employ the method of demonstrating 
abnormal irritability of the sympathetic system. In the 
norm, instillation of a drop of a one per thousand solu- 
tion of adrenalin into the eye has no effect on the dilator 
pupillae (page 452), but if the sympathetic system is ex- 
citable, pronounced mydriasis follows the instillation 
(The nerve-fibers for the dilator muscle of the pupil run 
in the cervical sympathetic and terminate in the superior 
cervical ganglion) . To further demonstrate the value of 
the author's tests, the following may be cited: A patient 
fond of coffee, invariably suffers after its use from tachy- 
cardia and arrhythmia. Prior to its use, the tone of the 
vagus was found normal (page 469). Within one-half 
hour after consuming coffee, the vagus-tone was absent, 
the heart was arrhythmic and the pulse 1 20. Within one 
hour after the use of pilocarpin (gr. i-io) per os the vagus- 

522 



.*• 



Forms of Heart -Failure 

tone was restored to normal, arrhythmia inhibited and 
the pulse reduced to 80. The hypodermatic use of pilo- 
carpin (page 454), is followed by more rapid results. 

FORMS OF HEART-FAILURE. 

Heart-failure is chiefly a muscular question, although a 
neuro-muscular factor must not be ignored. In cardiac 
insufficiency (decompensation), it is the cardiac muscle 
(myocardium), which fails to do the work of the heart. 

1. Heart-failure of Inflammatory Origin. — ^This 
form includes inflammation of the myocardium, endocar- 
dium and pericardium. 

One of the most common etiologic factors in the inflam- 
matory involvement of these structures is rheumatism. The 
pyogenic cocci, pneumococcus and gonococcus also play a 
very important rble in etiology. In fact, metastatic infection 
is exceedingly common. TofisiliHsy heretofore regarded as 
a trivial affection is now viewed as a grave one, insomuch as 
it is often the only recognizable cause of endocarditis, poly- 
arthritis and other diseases. 

If polyarthritis is caused by suppurating tonsillar crypts, 
incision or removal of the latter may cause an immediate 
disappearance of pain and fever. A bacteriologic study of 
the tonsillar crypts will reveal all kinds of micro-organisms, 
and the wonder is that the tonsils are not more often accused 
as factors in the etiology of disease. 

2. Heart- failure of Arteriosclerotic Origin. — 
The circulatory apparatus must be regarded as a unit. In the 
embryo, the heart is only a blood-vessel and its elaboration 
into a special organ is only the result of muscular overgrowth 
which in one situation make a heart and in another, the wall 
of a blood-vessel. 

In arteriosclerosis^ the hypertrophy of the heart ensues 



S p 



I 



a p y" 



from an increase in tlie peripheral resistance of the blood- 
vessels. Soon, however, dilatation of the organ ensues.witi 
signs of decompensation (dyspnea on exertion, attacks of ■ 
cardiac asthma, scanty urine, etc.). It is usual to specify a 
renal form of heart-failure, but such a form is identified with 
arteriosclerosis in such a way that it is difficult to say which 
is primary and which is secondary, 

3. Heart-failure from Obesity. — Oertel first ex- 
plained the effects of obesity on the heart and blood-vessels. 
Indeed, heart failure is more frequendy encountered in i 
than in lean individuals. 

A fatal error is often made in the treatment of these cases 
when an attempt is made to execute a reduction-cure with- 
out first strengthening the myocardium. Naturally, one , 
must eventually reduce the weight, but care must always \ 
exercised to reduce gradually and to avoid subalimcntation, 
It is better to provide the patient with about i ,600 calories I 
day to attain our goal more slowly. 

Thyroid intoxication, the cardiac neuroses, in fact i 
cause operating to increase unduly the work of the hei 
eventuates in failure of the organ. 

Heart-failure from syphilis (congenital or acquired), is 
not infrequent. Some forms of myocarditis are always 
syphilitic. In the presence of symptoms of cardiac insuffi- 
ciency in a subject with a history of syphilis, the latter a 
etiologic factor is not only possible, but probable. 
Here the use of mercurial inunctions is indicated: 
In Pulmonary Edema, the tonicity of the right ventri- 
cle is implicated and its dilatation is manifested by cyan- 
osis, dyspnea and pulmonary edema. 

Referring to page 202, one finds that the myopathic 

heart reflex only influences the right ventricle of the 

heart. Percussion of the muscles is a puissant method of 

tieatment in pulmonary edema. 

524 



Cardiac Murmurs of Functional Origin 



CARDIAC MURMURS OF FUNCTIONAL ORIGIN. 

Perhaps no fallacy in medicine has been more sacredly 
perpetuated than the belief that a cardiac murmur is always 
indicative of a disease of the heart. Some of the most serious 
heart-aflFections are unaccompanied by murmurs. "The 
idea that a murmur in itself and by itself is a serious thing 
dies hard." (Shattuck). 

Sir Andrew Clark gave utterance to the truism that ''a 
murmur in itself is of little or no moment in determining the 
prognosis of any given case." Osier voices the opinion of 
the skilled cardiac diagnostician as follows: "Practitioners 
who are not adepts in auscultation and feel unable to estimate 
the value of the various heart-murmurs should remember 
that the best judgment of the conditions may be gathered 
from inspection and palpation. With an apex-beat in the 
normal situation and regular in rhythm, the auscultatory 
phenomena may be practically disregarded." Fowler is 
responsible for the epigram: "The position of the heart- 
apex is the key to the diagnosis of nearly all aflFections of the 
chest and heart." 

Functional Aortarctta and Aortectasis. — ^These 
terms refer respectively to contraction and to dilatation of the 
aorta. It is known that, when the lumen of an elastic- 
walled tube through which liquid flows is narrowed, eddies 
are created which cause the walls of the tube to vibrate and 
eventuate in a palpable thrill and a blowing sound called a 
murmur. The latter is loudest below the narrowing and is 
transmitted in the direction of the flow. 

By means of the aortic reflexes (page 254), one may con- 
tract or dilate the aorta. 

If, after auscultating the aortic sounds, one executes 
concussion of the spine of the 7th cervical vertebra (reflex of 

525 



Spondyloth 



contraction), and again auscultates, a syslvlic aortic n 
is usually heard, varying in duration from one-half to three 
minutes. The murmur replacing the systolic tone is of 
longer duration than the latter. It is observed in the norm 
in children as well as in adults and is equally pronounced in 
arteriosclerosis of the aorta. My primary endeavor to utilize 
this auscultatory sign as an evidence of loss of elasticity of 
the aorta was therefore futile. The murmur in question is 
the result of temporary aortarctia (aortic contraction), super- 
induced by elicitation of the aortic reflex of contraction, ancti 
it may be dissipated at once by provoking the counter aortifiT 
reflex which dilates the aorta. 

In several instances only, was the author able to crea*^ 
a diastolic aortic murmur by elicitation of the aortic reflex c 
dilatation. 

Reflex of the Pulmonary Arterv. — As a rule, simul^ 
taneously with the creation of a systolic aortic murmur, a 
systohc murmur was also audible over the pulmonary artery. 
Indeed, it was often heard in the latter situation, although 
inaudible over the aorta. It was specially loud in children. 
Like the aortic systolic murmur, it was at once dissipated by 
elicitation of the aortic reflex of dilatation (concussion of the 
4 lower dorsal spines). Although the pulmonary artery 
eludes percussion, the auscultatory evidence just cited would 
seem to show that there are likewise two reflexes of the pul 
monary artery, I'/s.— contraction and dilatation. 

Deductions. — Aside from the inestimable value of tli 
aortic reflex of contraction in the treatment of aneurysms,! 
the reflexes of the pulmonary artery and aorta subserve i 
useful object in diagnosis. Thus dilatation of these ^ 
may exist, for the calibre of the large arteries is never coi 
stant. 

If, then, at an inauspicious moment, one were to ausc 
526 



D e d u 



n 



tate either artery and a diastolic murmur were heard, a 
faulty diagnosis would be made. Such diagnostic errors are 
frequent. However, having recognized the physiologic 
rhythmicity of the large vessels (page 620), one would at 
once execute the method for provoking contraction of these 
vessels by concussion of the 7th cervical spine and the dias- 
tolic murmur would be dissipated if it were wholly caused by 
dilatation of the large vessels. 

Similarly, a systolic murmur caused by narrowing of the 
aorta and pulmonary artery would evanesce after concussion 
of the spines of the four lower dorsal vertebrae. 

The auscultatory phenomenon with reference to the reflex 
of contraction of the pulmonary artery directs our attention 
to the incorrect apodictic pronunciamento of some physiol- 
ogists who aver that the pulmonary blood-vessels are 
unprovided with vasomotor nerves. From what has pre- 
ceded, the pulmonary artery must be under vasomotor 
control. 

Dr. H. C. Sawyer, of San Francisco, directed my attention 
to the fact that in the treatment of aneurysms of the thoracic 
aorta by the author's method of concussion of the 7th cervical 
spine, aneurysmal murmurs would disappear for a variable 
period of time after treatment. Even the patient who was 
conscious of the murmur noted its disappearance for about 
four hours after treatment. Since my attention was directed 
to this sign by Dr. Sawyer, I have also observed the tempor- 
ary disappearance of the thrill. In a number of instances, 
however, the aneurysmal murmur did not completely dis- 
appear, but only became less loud. 

Murmurs are so conmionly encountered without valvular 
lesions that Laennec was constrained to conclude that they 
were of no diagnostic importance, whatever. Laennec's 
observation is worthy of citation, despite its falsity, in direct- 

527 



S p n d y I 



h 



ing attention to the frequency of functional or accidental 
murmurs. 

Potain found accidental murmurs in one-eighth of all the I 
patients seen in his hospital service. 

Many theories have been suggested in explanation of the 
accidental murmurs, but the author believes, based on the 
maneuvers suggested for their creation and disappearance, 
that they are caused by a functional stenosis or dilatation of 1 
the aorta and pulmonary artery. Later (page 604), we shall I 
learn the relation of functional pulmonary stenosis to tuber-l 
culosis. 

Careful percussion of the thoracic aorta by the author, 
together with measurements of the vessel by the ortho- 
diagraph several times a day on the same patient, show 
the variations in the calibre of the aorta in accordance 
with the law that, each part of the body receives an 
amount of blood necessary for its activity. The diag- 
nosis of murmurs of relative valvular insufficiency has 
been noted on page 209. 

Inhibition of the Heart (page 228) — This phenome- 
non may be utilized in diagnosis. It may be elicited by exten- 
sion of the muscles of the neck (Fig. 65}, or by contraction of 
the abdominal musculature (page 208). The employment of 
the phenomenon is based on the fact that the loudness of a 
murmur is largely dependent on the activity of the heart. 
Thus, in weakness of the heart in febrile diseases and the 
dying state, murmurs become less loud or disappear. Dur- 
ing the time inhibition is properly executed, cardiac tones 
and murmurs diminish in intensity. A few seconds usually 
elapse before the effect on the heart becomes manifest, then, , 
while the subject is still inhibiting the organ, the heart tones J 
become less and less evident, assuming an embryocardu 
character, until finally they are no longer audible. 
528 



Intra-Abdominal In sufficiency 

My investigations with this method may be summarized 
as follows : 

1. Organic murmurs become faint and almost inaudi- 

ble. 

2. Transmitted murmurs are more amenable to inhibi- 

tion and when they are inhibited, the tones which 
they mask can be auscultated. 

3. The fainter the murmur, the more easily it is inhib- 

ited. 

4. Heart-tones are less amenable to inhibition than 

murmurs. 

5. Functional, are more easily inhibited than organic 

murmurs and when tones replace the murmurs, 
the functional nature of the latter is determined. 

6. Incorrect execution of inhibition will intensify rather 

than diminish murmurs and repetition of the 
maneuver eventuates in futile results owing to 
exhaustion of the vagi. 

Intra-abdominal Insuffictency. — The frequency im- 
portance and neglect to recognize this condition prompts the 
author to make supplementary observations in addition to 
those cited on page 145. The condition in question is 
practically identical with Gl^nard's disease (page 349), but 
if the physician is guided in the diagnosis of this affection by 
the palpation of prolapsed abdominal viscera, intra-abdomi- 
nal insufficiency will often escape recognition. In asso- 
ciation with the signs noted on page 145, one seeks for the 
symptoms identified with intra-abdominal venous congestion 
(page 427). 

Cardioptosis or ptosis of the heart is a participating 
phenomenon of intra-abdominal insufl&ciency. The position 
of the diaphragm and with it the heart, is influenced by intra- 
abdominal tension. The latter is maintained by pressure 
of the atmosphere on the yielding abdominal parietes and 

529 



S p n d y I t h e r a p y 

contraction of the abdominal muscles. Artificial reduction 
of intra-abdominal pressure by means of a large vacuum 
cup applied to the abdominal wall will often, as long as 
suction is maintained, cause the appearance of systolic 
pulmonary and aortic murmurs. The former, however, less 
frequent than the latter. 

The systolic aortic murmur of cardioptosis is associated 
with signs peculiar to the latter, viz.^ cyanosis, dyspnea on 
exertion or in certain attitudes, and weight or oppression in 
the lower sternal region or epigastrium. The disappearance 
of the cardiac murmur and the temporary relief afforded by 
lifting the abdomen and the almost immediate and per- 
manent relief following the wearing of a proper abdominal 
support, with the chief pressure at the umbilical region^ are 
diagnostic-therapeutic signs. • 

It is surprising to note the large number of individuals 
with neurasthenic and digestive symptoms caused by 
intra-abdominal insufficiency. These patients are treated 
futilely for every conceivable condition but the right one. 
In advanced grades of the condition, the ^^ habitus enter- 
optoticus seu paralyticus^^ may be recognized. Stiller 
insists that a fluctuating or floating tenth rib {costa 
decima fluctuans) is pathognomonic of this condition. 
In Stiller^s book, "The Asthenic Diathesis," he shows 
that the patients digest quite well until fatigued. Mucous 
colitis is often associated with the condition. Mere in- 
spection may enable one to make a diagnosis when the 
patient is standing, viz., long and flat thorax with narrow 
epigastric angle, retracted and flat abdomen in epi- 
gastrium and protuberant lower abdomen. Prolapsed 
organs may be palpated in the recumbent posture. 

These patients are best treated by hyperalimentation 
and an abdominal support. We must not forget however, 
that the victims of intra-abdominal insufficiency may be 
obese as well as emaciated. 

530 



In tr a - Abdominal Insufficiency 



Before a permanent abdominal support is obtained, 
one may temporize with Rose's method of strapping the 
abdomen for detennining whether gastric, cardiac, neu- 
rasthenic and other symptoms are dependent on intra- 
abdominal insufficiency. The plaster may be worn for 
a week or longer. Z. O. adhesive plaster on moleskin 
(Johnson and Johnson) is used, seven inches wide and 
as long as the circumference of the waist measure of the 




Fig. 130. — Illusliating tbe method of Rose in the application of the plaster 
bandage. The figure above shows the method of cutting the plaster and the other 
figures show respectively, the method of applying the strip A, and the strips B, B, 
which complete the bandage- 
patient. This plaster is cut into three pieces according 
to &gure. The abdomen is shaved and washed with 
ether. Tbe large piece is first applied, the point bang 
placed over the symphysis, the ends meeting and over- 
lapping in the back. The plaster should be applied 
above the crest of the ilium. Then the side-pieces, which 
run from the hypogastrium over the iliac and inguinal 
regions and unite at the spine, are applied with consid- 
erable force. 

531 



Spondyloth e r a p y 

I usually apply the plaster in the Trendelenburg posi- 
tion although the dorsal posture may be used, the ab- 
dominal viscera being raised by an assistant during the 
time the plaster is tightly approximated to the back. 
The removal of the plaster is facilitated by benzine or oil 
of wintergreen. 

Another method '*», more satisfactory than the latter 
for supporting the abdomen is the following which is 
illustrated in Fig. 121. 




Fig. 121. — Illustrating a method for supporting the abdomen. A indicates 
double-padded bandage and B, zinc oxid strip. 

"A strip of zinc oxid adhesive plaster 2 or 2i inches 
wide and about 5 or 6 inches long, the length varying with 
the size of the patient, is placed transversely across the 
extreme lower abdomen as nearly as possible to the pubes, 
the hair having been shaved clean for this purpose. To 
each end of this strip of adhesive plaster is attached a 
bandage of about the same width, long enough to reach 
around the body above the iliac crest, and be tied or 
otherwise fastened behind, or better, one end long enough 
to reach around and fasten at opposite end of plaster. 
If the ends of the plaster have a tendency to become 
loosened and pull up by traction of the bandage, this 
can be prevented by a narrow verticle strip across each 
end of the adhesive strap and applied to the skin above 
and below. The bandage itself is well padded with cot- 
ton, either folded within it or applied to the body imme- 

532 



Subclavian Murmurs 

diately beneath it. This prevents any irritation of the 
skin from the bandage and permits of its being drawn 
as tightly as necessary in order to furnish the necessary 
support from below." 

The point of pressure in the lower abdominal area 
gives the greatest amount of support. Where the plaster 
approximates the skin, a thin layer of collodion to the 
latter may precede the application of the bandage. 

Any abdominal condition causing the diaphragm to be 
forced upward may cause functional murmurs and the hori- 
zontal position of the heart with an apparent increase in the 
transverse diameter may still further complicate the situation. 

SUBCLAVIAN MURMURS. 

Subclavian murmurs are frequently misinterpreted as 
evidence of an aneurysm or cardiac disease. The literature 
on the subject is meager and indefinite and for that reason I 
may be pardoned for interpolating my investigations. 

From the literature the following facts were gleaned: 
Subclavian murmurs are sounds heard over the sub- 
clavian artery which are dependent on the phases of 
respiration. They are usually best heard at the height 
of inspiration, less often at the end of expiration. When 
very intense, they may be recognized by the finger as 
fr^missemetU. They are heard more often on the left than 
on the right side, rarely on both sides, and least often on 
the right side. English practitioners of medicine have 
been especially prominent in the study of the phenome- 
non, and have regarded it as a clinical sign of pulmonary 
tuberculosis when it is only manifest on one side. This 
opinion was combated by Fuller and Palmer. The 
former found the subclavian murmur twelve times among 
one hundred healthy persons, whereas Palmer found it 
to exist thirty-seven times among one hundred and 
twenty-nine healthy laborers. 

533 



S p 



p y 



Mechanism of thk SriirLAViAN Murmur. — The 
mechanism of its origin has not been made definite, al- 
though it has been variously attributed to compression 
of the subclavian artery by the elevation of the first rib 
in inspiration or to the action of the subclavius and 
scaleni muscles. Friedreich, observed the subclaWan 
murmur most frequently among phthisical individuals, 
and suggested as a cause, the occurrence of adhesions be- 
tween the vessel wall and the lung pleura, which led to a 
narrowing of the artery in one or both phases of respira- 
tion. He contended that, insomuch as pleural adhesions 
were not infrequent, even among healthy persons, he was 
constrained to conclude that such adhesions sufficed to 
explain all subclavian murmurs, the extent and direction 
of the synechia; deternnining the occurrence of (he mur- 
mur during inspiration or expiration. From an exam- 
ination of more than three hundred persons, I am able 
to formulate the following conclusions: 

[. The subclavian arterial murmur is an independent 
(autochthon) and rarely a transmitted murmur. 

a. Its point of maximum intensity is the fossa of 
Mohrenheim, with feeble tendency to propagation. 
The fossa of Mohrenheim is that depression under the 
clavicle in the outer part of the infraclavicular region be- 
tween the pectoralis major and deltoid muscles. 

3. It is heard most often on the left side, less fre- 
quently on both sides, and least frequently on the right 
side. In order of frequency it is heard at the height of 
inspiration, at the end of expiration, and after momen- 
tary suspension of respiration. 

4. It is usually a succession of murmurs uniform in 
character and intensiSed by certain maneuvers, notably 
deep inspiration, forced expiration, suspension of respir- 
ation, and voluntary stretching of the neck. 

5. One of the chief characteristics is its momentary 
duration, disappearing usually after a few deep inspira- 
tions. 



534 



Anatomic Conditions 

6. Its dependence on the phases of respiration dis- 
tinguishes it from all transmitted murmurs. 

7. It may be present at one and absent at a subse- 
quent examination, and neither its character nor dura- 
tion is ever uniform from one examination to another. 

8. The position of the patient may influence its gen- 
esis, but this is never sufl5ciently uniform to be of prac- 
tical value. 

9. A phthisical lung is not specially propitious to its 
occurrence, as it is found nearly as often in healthy as in 
phthisical persons. 

10 It was present in 36 per cent, of all healthy per- 
sons examined, advantage being taken in this enumera- 
tion of re-examinations and those propitious factors 
which determine its occurrence, viz., respiration and 
decubitus. 

1 1 . The venous subclavian murmur was only heard in 
six individuals with a preponderance of its occurrence on 
the right side. 

12. The arterial subclavian murmur could be artifi- 
cially induced on the left side in nearly 80 per cent, of all 
individuals examined, and on the right side in about 65 
per cent, of the cases by a simple maneuver, viz., raising the 
arm gradually until it assumes a vertical position, while 
auscultating the Mohrenheim fossa during the time that 
the arm is brought to the latter position, the murmur 
suddenly appearing at some time during the execution of 
the movement. 

13. By the foregoing maneuver the subclavian venous 
murmur could be induced on the right side in 43 per cent, 
of all persons examined. 

Anatomic Conditions. — To explain the origin of the 
subclavian, arterial, and venous murmurs, a short ex- 
cursion into the realms of anatomy is necessary. The 
right subclavian artery arises from the arteria innominata 
whereas the same vessel on the left side arises from the 
end of the transverse portion of the arch of the aorta. 
The left subclavian artery is longer than the right and 

535 



S p 



t h 



r a p y 



directed almost vertically upward, instead of arching 
outward, like the vessel of ihe opposite side. The inner 
aspects of the upper lobes of both lungs are occupied by 
grooves, one on each side, tor the subclavian vessels, 
where they are invested by the pleura. The third por- 
tion of each subclavian artery on the outer surface of the 
first rib, and at the lower border of this bone becomes 
the axillary artery. The points in connection with the 
first rib that suggest attention are the tubercle and ridge, 
which serve for the attachment of the scalenus anticus 
muscle, the groove in front of it transmitting the subclav- 
ian vein, that behind it the subclavian artery. Both 
subclavian veins, which are the continuation of the axil- 
lary veins, unite v^lh the internal jugulars to form the 
right and left vena innominata. If we auscultate the 
subclavian artery, we hear, in the majority of cases, just 
as we do in listening over the carotid, two clear tones, 
one corresponding with the tilling of the vessel, the dias- 
tolic, and the other with (he emptying of the vessel, the 
systolic lone. Less often only one tone is heard, which 
is usually coincident with the systole of the blood-vessel. 
The tones thus heard are Ihe transmitted first and second 
aortic tones. If we press moderately with the stetho- 
scope, let us say, the carotid artery, we hear a pressure- 
murmur corresponding to the arterial pulse; by stronger 
pressure, which almost, but not quite, doses the artery, 
this murmur is changed into a tone, the so-called pi 
sure-tone. With these preliminary facts at our disposal, 
we can make explicable the subclavian murmur as heard 
in health. The following facts demand solution: 

I. Why is the subclavian murmur heard loudest dur- 
ing forced inspiration and expiration? 

a. Why is the murmur of short duration, disappear- 
ing after a few deep inspirations? 

3. Why is the murmur heard more often on the left 
than on the right side? 

Factors Necessary for Its Production, — The es- 
sential factor necessary in the production of the subdav- 

536 



Anatomic Conditions 

ian murmur is a moderate narrowing of the lumen of the 
blood-vessel. The recorded frequency of the subclavian 
murmur in phthisis, and its explanation that pleural 
adhesions are responsible for its occurrence, is in a meas- 
ure untenable, for such a condition presumes a narrow- 
ing of the blood-vessel that would be persistent at some 
phase of the respiratory act. My observations show 
that the murmur occurring in phthisis is just as transitory 
as it is in health. Moderate narrowing of the subclavian 
artery occurs during forced inspiration. This is a fact 
which is easily demonstrable in almost any individual by 
palpation of the radial pulse. In not a few instances 
deep inspiration will cause the radial pulse, especially 
the left, to disappear. The paradoxic pulse has lost much 
of its clinical significance as a diagnostic aid in med- 
iastino-pericarditis, since observations have shown that 
in health distiact respiratory changes in the pulse are 
demonstrable by means of the sphygmograph. The 
sphygmogram shows a fall in the pulse-curve during in- 
spiration and a rise during expiration. Deep, prolonged 
inspiration, by elevating the first rib, effects compression 
of the subclavian artery, which accounts for the murmur, 
which is really a pressure-murmur. Violent contraction 
of the muscles of inspiration or forced contraction of the 
muscles which draw the shoulder forward while the arm 
is at the side will change the murmur into a tone — the 
pressure-tone. The occurrence of the murmur only dur- 
ing expiration may be explained in part by the fact that 
after the artery is excessively compressed by the act of in- 
spiration, this pressure is in part removed during the be- 
ginning of expiration, which act converts s^ pressure-tone 
into a pressure-murmur. Then again the blood-pressure 
must be taken into account during the expiratory act. 
Stretching of the neck, which will sometimes elicit the 
murmur, is explained by the action of the scalenus med- 
ius elevating the fifth rib. The short duration of the 
murmur finds explanation in the artificial production of 
the pressure-murmur in the normal artery. Here, as in 

537 



S p 



t h 



a p 



the normal arlery, ihe ever-increasing narrowing of the 
lumen of ihc subclavian artery will convert a murmur 
into a tone. This is practically what occurs during forced 
inspiration, for a murmur heard during the beginning of 
the inspiratory act may no longer be audible at the end 
of that act. Then again attention must be directed to a 
condition (page agg), which Kernig and myself have 
described, viz., a complete dulness of the lung-apices 
without any structural change in the lung. In many 
healthy persons this condition is manifest. It is not 
difficult to conceive that the subclarian artery would be 
more effectually compressed by an atelectatic upper 
lung-lobe than by an aerated lobe. After a few deep 
inspirations the subclavian murmur is no longer e^^dent, 
owing, perhaps, tc the fact that the apices becoming 
more aerated offer less resistance to the superimposed 
arteries. The more frequent occurrence of the murmur 
on the left side finds facile explanation in the anatomic 
diSerences between the two arteries; the left reacting 
more easily than the right subclavian artery to the in- 
fluence of those factors which conduce to compression of 
the blood-vessels. 

Means by Which the Murmdr May Be Elicited. — 
The method I have advocated for eliciting the subclavian 
murmur is simple. Placing the pectoral end of our 
stethoscope in the fossa of Mohrenheim, we listen (or the 
subclavian murmur. If the latter is not heard, we slowly 
raise the arm of the patient corresponding to the side 
auscultated until it is audible. The murmur may not be 
demonstrable until the arm is elevated to a level with the 
shoulder or until it assumes a vertical position. This 
maneuver evokes the subclavian phenomenon by narrow- 
ing the lumen of the subclavian artery, for coincident with 
the elevation of the arm the radial pulse becomes less and 
less evident, until, when the arm has attained the vertical 
position, the pulse is no longer palpable. This diminu- 
tion in the pulse-volume is more manifest on the left than 
on the right side. In a certain percentage of. persons ex- 

SJ8 



Angina Pectoris 

amined, the maneuver of raising the arm gave rise to a 
subclavian venous instead of an arterial murmur, while 
in other persons both murmurs were distinctly audible. 
The soft, musical, continuous hum of the venous mur- 
mur cannot be confounded with the arterial murmur. 
Like the artificial venous murmurs produced by pressure 
of one of the large veins by means of our stethoscope, so 
may the subclavian venous murmur be explained, viz., 
that by raising the arm we elevate the first rib, which in 
turn narrows the subclavian vein. The more frequent 
occurrence of the subclavian venous murmur on the 
right side is explained in the same way as we explain the 
increased irequency of the jugular venous murmur on 
the same sfde. 

ANGINA PECTORIS.* 

Anginoid pains are symptomatic of a variety of cardiac 
affections and are equally independent of the latter. We 
shall first diflFerentiate the so-called varieties of angina 
pectoris (stenocardia). 

1. Angina Abdominis. — Here, the spasm is confined to 
the vessels innervated by the splanchnic nerve, causing an 
enormous increase of blood-pressure. Even in true angina 
there are attacks of abdominal pain suggesting gall-stone 
colic. 

2. Angina Pectoris Vasomotoria. — ^Here, there is no 
primary cardiac lesion, but a wide-spread arterial spasm 
with secondary anginoid pains. The peripheral angiospasm 
causes paresthesias in the hands and feet, and if the pale 
and cold (often cyanotic) extremities are warmed, or if the 
patient walks, anginoid pains are inhibited. 

3. Angina Pectoris from Coronary Sclerosis. — In 
this true form of the disease the lesion in the majority of 



♦ViJtf, page 221, ei seq. 

539 



S p n d y I 



t h 



instances is an arteriosclerosis of the coronary arteries. The] 
pains are probably caused by an ischemia of the myocar- 1 
dium (page 222), which fact is supported by the observation J 
that the pains diminish in frequency as age advances, owing 
either to muscular insufficiency or because the too-rigiq 
vessels do not permit of vasoconstriction. 

Etiology of Anginoid Pains. — Practically any painful 
abdominal affection, notably gastric ulcer, may simulate the 
pains of angina pectoris. In endocarditis and perhaps in 
obesity (if coronary arteriosclerosis is not present), narrowing 
of the coronary vessels may conduce to attacks of angina. 
Pericardial adhesions may also narrow the lumina of the 
vessels. Syphilis of the Jieari is not an infrequent factor. 
Probably the lesion is more often aortic (implication of the 
region corresponding to the origin of the coronary arteries). 1 
Here, antisyphilitic treatment may establish the diagnosis. I 
Tubes dorsalis (cardiac crises), gout, diabetes, lead poisoning, 
hyperthyroidism, auloinloxicalioji and nervous affections may 1 
cause anginoid pains. 

Tobacco is no doubt a frequent etiologic factor in angina. 
When tobacco or alcohol Is the problematic cause, the pres- 
ence of scolomala (blind spots in the visual-field), will clinch 
the diagnosis. 

TeU for scolomala. — Let patient with one eye dosed 
look steadily at tip of physician's nose at a distance of 
about two feet; then take any green or red colored object 
(wool or card board), about 2 lo 5 mm. in diameter, and 
move it from the periphery to the point of fixation; when 
the object arrives at the scotoma (seat of defect in the 
visual-field), it will appear dull or colorless. Green is 
usually less readily perceived than red. 

Osier," presages an increasing number of cases of angini 

pectoris (cardiac neuralgia), corresponding with the rapid 

540 



A 



n g t n a 



e c t r t s 



increase of cigarette smoking among women. He observes 
that very heavy smokers may die from vagus-inhibition. 

In investigating the influence of tobacco on the heart, I 
noted that in some individuals the blood-pressure was re- 
duced and in other instances, it was raised. The effects 
thus produced corresponded to its sedative or stimulating 
action. The chief effect, however, was on the cardiac 
musculature, tobacco eliciting a veritable heart reflex lasting 
from one minute to several hours. This effect was accent- 
uated when the tobacco was inhaled and partially inhibited 
when the smoke was filtered through cotton. The effects 
varied with the kind of tobacco smoked. Thus, in some 
individuals, Havana tobacco produced a marked retraction 
of the left ventricle, whereas, Turkish tobacco was without 
any effect. 

In my investigations, the effects of tobacco were not 
only tested with reference to the heart reflex but by other 
methods for testing vagus-one (page 469). 

Insomuch as tobacco is a vagus-tonic, I do not pro- 
hibit its use among my patients who suffer from aneur- 
ysms or myocardial affections (excluding angina pectoris). 

To illustrate my investigations, the following two cases 

are cited : 

CASE I 







AMPLITUDE OF 


DURATION OF 






RETRACTION OF 


HEART 






LEFT VENTRICLE 


REFLEX 


a. Havana cigar partially smoked 
h. Same cigar smoked through 
cotton in a holder 


a, 3.5 cm. 

h. No retraction. 


a. 2 min. 


c, Manila cigar without cotton 


c, 4 cm. 


c. 4 min. 


d. Manila cigar with cotton 




d, 2 cm. 


d, 3 min. 




CASE II 




Same condition as a 




2.5 cm. 


2 min. 


Same condition as h 




No retraction. 




Same condition as c 




4 cm. 


7 min. 


Same condition as d 




No retraction. 






541 





Spondylotherapy 

It is quite probable that anginal pains from tobacco are 
caused by ischemia of the myocardium superinduced by 
the heart reflex. 

Anginoid pains are not infrequent in aneurysms and 
Osier refers to angina pectoris as an early symptom of the 
disease, due probably to overstretching of the aorta. 

Here, concussion of the seventh cervical spine (which 
contracts the aorta), will cause an immediate evanescence of 
the pain, whereas, the maneuver, which likewise contracts 
the heart' will increase the pains in true angina (page 223). 

With increasing experience in the treatment of angina 
pectoris, the author is constrained to make a dogmatic 
differentiation of the disease into two forms: Angina, with- 
out and with an increase in the diameters of the heart. 

Angina without Dilatation. — It is not only necessary 
to demonstrate that the heart is not dilated, but also to 
establish the fact by the method cited on page 510, that the 
myocardium is efficient. WTien the myocardium is efficient 
and the heart is not dilated, the angina is probably caused by 
coronary arteriosclerosis. If examination shows a dilatation 
of the organ and an inefficient myocardium, the pains are 
caused by an acute or chronic dilatation of the heart. 

I shall differentiate these two forms as cardio-tonic (no 
increase in cardiac diameters), and cardiectatic angina 
pectoris. 

The tone of the myocardium, as has already been shown 
(page 471), is maintained by vagus-tone, and any increase 
in the latter will precipitate a cardio-tonic paroxysm of 
angina. It is in this way only that one may explain attacks 
caused by the action of digitalis, pilocarpin and concussion 
of the 7th cervical spine, which increase vagus-tone. Atropin 
inhibits the pains of the cardio-tonic variety and accentuates 
the pains of the cardiectatic forms. 

542 



Cardiectatic Angina Pectoris 

Concussion of the 7th cervical spine will cure the car- 
diectatic forms. 

By inhibiting vagus-tone (concussion or sinusoidalization 
of the region corresponding to the third and fourth dorsal 
spines), the author has achieved promising results in the 
treatment of cardio-tonic angina pectoris. This corresponds 
to the method on page 221, for eliciting the heart reflex of 
dilatation; the dilatation by this method being to evoke an 
active dilatation of the organ (page 520). 

Cardiectatic Angina Pectoris. — Investigations by 
Hyde, in Porter's laboratory, show that dilatation of the heart 
alone will diminish the flow of blood through the coronary 
arteries. It is for the latter reason that the pains associated 
with dilatation may be subdued by withdrawing some blood. 

Among the soldiers of the Civil war, da Costa noted 
precordial pains of anginoid intensity, due to overstrain and 
dilatation of the heart. Acute cardiac dilatation, such as is 
observed after physical exertion (climbing, dancing, rowing, 
running, etc.), causes anginoid pains. 

Within a few days, treatment by concussion causes the 
disappearance of symptoms peculiar to dilatation of the 
heart. 

The following case of a San Francisco physician is 
cited to illustrate the importance of recognizing the 
cardiectatic variety of angina pectoris. My stenog- 
rapher's verbatim report from the physician is as follows: 
"My age is 52 and weight, 172 pounds. Several promi- 
nent physicians (names suppressed) diagnosed my case 
as one of true angina pectoris and I was doomed to live 
a life of hopeless invalidism. My father suffered from 
similar attacks of anginal pains which began at my age. 
He was like myself inclined to obesity. I am forced to give 
up my outside practice, because the least exertion in 
walking and particularly when the cold air strikes my 

543 



S p 



t h 



chesl brings on severe and radiating pains with a feeling 
of fear and oppression." 

In this patient, the cardiectatic variety of angina was 
demonstrated. Within three weeks, the patient was able 
to resume his practice and up to the time of writing 
could make any physical exertion without any recurrence 
of symptoms. Concussion of the seventh cervical spine 
(daily stances, ten minutes) was the only treatment em- 
ployed. Provision later, however, was made for a grad- 
ual reduction in weight for it is impossible to fully re- 
construct cardiac musculature immersed in an at- 
mosphere of fat. The fact that the patient's father had 
dmilar attacks at his age only emphasized heredity in 
relation to the tendency to corpulency which impaired 
the integrity of the cardiac musculature. 

The fact in the previous history, that "cold air striking™ 
the chest" precipitated an attack, led me to investigate this 
phenomenon which is by no means uncommon in angina 
pectoris. Some patients also suffer from attacks when coldj 
air is inspired. I found that when a current of cold air is J 
directed over the precordial region, the heart dilates. In the 
norm this dilatation is slight, but it is exaggerated in cardiac 
insufficiency. Inhalation of cold air produces a like, though 
less pronounced effect. This heart reile.x of dilatation (pages 
221 and 520}, like its counter reflex of contraction, is mediated 
by the vagus, for, when the latter is inhibited (pressure 
between the 3d and 4th dorsal spines), no reflex can be elicited 
A current of warm air over the heart is neutral in action. 

The foregoing observation is of great physiologic and 
therapeutic value. As a rule, cold air impinging on a 
visceral area is in the nature of a cutaneous irritant and 
one would premise that the result would be a contraction 
of an organ, like the heart reflex of contraction and other 
visceral reflexes. It was found that cold air similarly used, 
dilated Ike stomach, spleen and liver. The physiologist 
544 



Differential Diagnosis of Chest-Pain 

has extended the scope of the cutaneoiis sensory nerves 
by not only endowing them with the sensation of touch, 
but of pressure, warmth, cold and pain. He must now 
recognize the puissance of specific cutaneous nerves 
(page 465), which influence visceral-tone; nerves, which 
in response to a special irritant, will either contract or 
dilate an organ. A better understanding is also had of 
percutaneous medication. Thus, Short and Salisbury^, 
endeavor to show by scientific investigations that applica- 
tions to the skin (ointments, lotions, plasters), are abso- 
lutely without value as determined by methods of testing 
the cutaneous sensations. In fact, many recognized 
local anesthestics applied to the unbroken skin rarely 
produced an anesthesia. In view of the author's ob- 
servations, such investigations which do not take the 
visceral reflexes into consideration are futile. It is known 
that, stimulation of the respiratory center is greater 
through the cutaneous nerves than through the branches 
of the vagus to the respiratory organs. 

DIFFERENTIAL DIAGNOSIS OF CHEST-PAIN. 

It is by no means always easy to diflferentiate the pains of 
angina pectoris from other chest-pains, insomuch as there 
are many grades of true angina. Two factors make up a 
typic anginal paroxysm: pain {dolor pectoris)^ located in 
the sternum and radiating to the arm (usually the left), and 
a feeling of anguish and sense of inmiinent dissolution {angor 
animi). Among other typic signs are: increased blood- 
pressure, sensory areas of the skin (Figs. 23 and 24), and the 
relief of the paroxysms by amyl nitrite (page 226), or other 
vasodilators. 

Chest-pain may be caused by diseases of the heart, 
pericardium and vessels, pleura, lungs and bronchi, media- 
stinum, esophagus, intrathoracic nerves and nerves of the 
chest- wall, bones, joints and periosteum, mammary glands, 

545 



S p 



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skin and muscles. Space will not pennit me to discuss all 
these varieties of pain. 

Intercostal Neuralgia.— Fully 95 per cerU. (analysis 
by author of 1,000 cases), of all cases of chest-pain are caused 
by intercostal neuralgia (Chapter VI), and the immediate 
relief by paravertebral freezing constitutes one of the most 
brilliant triumphs of therapeutic medicine* This form of 
neuralgia is observed more often on the left than on the right 
side, owing, as Henle supposed, to the fact that the veins on 
the right side pour their blood into the great veins by a less 
circuitous route. 

Occasionally one finds intercostal pains secondary to 
intrathoracic tumors, aneurysms, diseases of the spinal cord 
and its membranes and skeletal mal-alignmati (foot-note, 
page 186 and page 123). 

Pains simulating intercostal neuralgia may be one of the 
frontier symptoms of gastric cancer and are caused by infil- 
tration of the paravertebral tissues. 

In the foregoing instances, freezing is negatively diag- 
nostic, insomuch as it affords no relief. 

According to Wolfs Law, which is generally accepted, 
every change in the form and function of the bones, or of 
their tunclion alone, eventuates in definite changes in 
their internal and external configuration in confonnity 
with the laws of mathematics. The shape of a bone is 
caused by the function it performs. In this sense, 
skeletal maUatignment may be produced by improper 
static conditions. Intercostal and other neuralgias 
(notably, sciatica) may be caused by changes in verte- 



•For the relief ot pain in !he inlcrvals of frecring, the author employs the following 
efiicient analgesic Eormula for a sitigle dose, which may be repealetl if necessary: 
Ca0cin, grains, i; pyramidon, grains, 5; phenacelin, grains, 5; sodium bicar- 
bonate, grains, 10; sodium bromid, grains, 10. Omng to their (teliqucscenrc 
the powders are dispensed in homeopathic: viitls. 



546 



Intercostal Neuralgia 

bral alignment alone. As a rule, in such instances, 
sciatica is secondary to lesions of the sacro-iliac joints 
(page in), for, when there is any restriction in the 
movements of the vertebral colunm, there is either an 
increase in motion in the sacro-iliac joints or there is a 
change in the inclination of the pelvis. 

Mal-alignment of the vertebrse of static or muscular 
origin (page 123) will exert pressure on the spinal nerves 
at their exit from the intervertebral foramina. 

This can be easily demonstrated on a cadaver or by 
the insertion of cylinders of wax in the foramina. Such 
pressure is equivalent to stimulation, notably if there b 
any anomaly of the spinal nerves. 

Weir-Mitchell has demonstrated that a nerve subjected 
to a thermic insult becomes swollen, congested and 
hemorrhages occur in the nerve. 

On page 123, reference is made to albuminuria caused 
by lordosis. 

My investigations show that, albuminuria is really 
caused by traction or pressure on the lumbar nerves. 
If one makes continuous pressure on either side of the 
second lumbar spine for about three minutes, one may 
even in the norm detect the presence of traces of albumin 
in the urine by aid of Tanret's reagent. 

About fifteen minutes Faradization of this region will 
as a rule, effect the same object and when the urine al- 
ready shows albumin as in nephritis, its quantity is very 
much increased. 

When the pains implicate an extremity, it is important 
to differentiate radicular pains from pains of a nerve 
trunk. 

Here, the essential point in differential diagnosis is in 
the distribution of the hypoesthesia or anesthesia as de- 
termined by the objective examination. A nerve-trunk 
represents a combination of an anterior motor and a 
posterior sensory root, and the latter in their intraspinal 
course are in relation with the dura mater and the verte- 
brae. If a lesion involves the sensory root within the 

547 



S p n d y I 



t h 



column, the sensory disturbance ensuing will have a 
radicular distribution. 

In aflections of a peripheral nervc-tnink, the seosory 
disturbance is distributed irregulariy in a longitudinal 
or oblique direction whereas when the root of the nerve 
is involved, the hypoesthcsia or anesthesia represents a 
regular longitudinal distribution parallel with the ajtis 
of the limb. 

Freezing aids in differentiating pains of peripheral and 
central origin (page i88) or the peripheral nerve-lrunk 
may be blocked. Thus in sciatica, a perineural injection 
into the nerve may be made with 50 cc. of normal salt 
solution containing one grain of bcta-eucain. The in- 
jection is made at the gluteal fold, midway between the 
tuberosity of the ischium and ihe great trochanter. The 
needle should be about 3 inches in length and should be 
directed upward and slightly inward. When the nerve 
is reached by the needle, there is a slight twitching of the 
leg. This injection is curative as well as diagnostic. 

The following case of a physician is cited to illustrate 
a sensory phenomenon, which I have frequently noted, 
when there are several sources in the excitation of pain. 

For about 6ve years, the patient suffered from agoniz- 
ing paroxysmal pains radiating from the precordium to 
the neck and left arm. The attacks were associated with 
a sense of suffocation, pressure in the chest and perspira- 
tion. Several physicians bad concurred in the diagnosis 
of true angina pectoris. Examination demonstrated a 
cervi CO -brachial neuralgia ( pseud o- angina, page 194). 
Freezing of the sensitive paravertebral areas brought 
immediate relief and cure after six stances. At each 
successive s(5ance, tiew points of paraverlebral tenderness 
developed and new areas in the distribution of pain (the 
former paravertebral areas of tenderness and areas oF 
pain having disappeared). 

The areas were no doubt present at the primary ex- 
amination but they were overwhelmed by the more in- 
tense areas elsewhere. This is in accordance with the 



548 



Phrenic N 



V 



Law of Weber: Sensations increase as the logarithm of 
the stimuli. Thus, a candle light will increase the illum- 
ination in a dimly-lighted cellar, but the light would not 
be in evidence in the bright simshine. This phenomenon 
from another view-point is in accordance with the physi- 
ologic dictum that ''any center mediating a definite reflex 
suffers a loss in excitability whenever it is acted upon 
at the same time by any other pathway not concerned in 
that particular reflex." 

Phrenic Nerve. — ^Among the intrathoracic nerves this 
nerve may be implicated in a veritable neuralgia. The 
phrenic nerve is distributed to the pleura, pericardium and 
diaphragm, and after piercing the latter it supplies the 
capsule of the liver, spleen and gall-ducts. This nerve 
springs chiefly from the fourth cervical nerve, although it 
usually receives a twig from the third and fifth cervical 
nerves. Referring to Fig. lo, it will be noted that its chief 
source of origin corresponds to the fourth cervical segment. 
We note further, that its exit corresponds to the second and 
third cervical spines. In pleurisy and pericarditis I have 
almost invariably found points of tenderness corresponding 
to the latter spines, and by freezing the areas of tenderness, 
I have not only inhibited, but arrested the pains of these 
affections. In a diagnostic sense the maneuver is equally 
valuable, although one must reckon on possible implication 
of the capsule of the liver, spleen and gall-ducts, likewise 
innervated by this nerve. 

In pleural pains, I have noted dermatomes connected 
with the fourth cervical segment (Figs. 23 and 24). 

It is known that, when pain is associated with pul- 
monary disease, it is usually caused by pleural involve- 
ment. 

In pneumonia and pleurisy, the chief pain is located in 
the abdomen. Here, the reflex pain is probably med- 

549 



Spondylotherapy 

iated by the phrenic nerve, which supplies the parietal 
peritoneum (page 416). In involvement of the struc- 
tures innervated by the phrenic, shotdder-pain is not 
infrequent. The skin of the shoulder is supplied by the 
fourth and fifth cervical nerves, hence, the reflex dis- 
tribution of pain (Fig. 22). 

Diaphragm Reflex. — ^When intermittent pressure is 
made between the second and third cervical spines, a slight 
protuberance is noted on one or both sides in the epigastrium 
under the costal borders, with a wave running between the 
two protuberances. The maneuver is executed with the 
patient in .the recumbent posture, knees flexed, head toward 
the window and at the end of expiration. The phenomenon 
is specified by the author as the diaphragm reflex. It is 
more constant than the phrenic shadow of Litten. It is 
absent in diseases of the phrenic nerves leading to spasm or 
paralysis of the diaphragm. 

ANEURYSM OF THE AORTA. 

Definition. — ^An aneurysm signifies, literally, a dila- 
tation, but there are nomenclators who insist in differen- 
tiating a dilatation from an aneurysm of the aorta. This, 
like many classifications of aneurysm, is essentially an 
anatomic and not a clinical question. Clinically, aortic 
dilatations may be divided into two groups, dilatations with- 
out (latent cases), and with symptoms * 

Prior to my recognition of the aortic reflexes, several 
of us saw a patient with pains radiating to the left arm 
and chest in whom the X-rays revealed simple aortic 

♦Even though an aortic dilatation is demonstrable, it is difficult to say what bearing 
it may have on the symptoms. The diagnostic-therapeutic test by daily con- 
cussion of the 7th cervical spine may be necessary for a decision. Within ten 
days, if aortectasis is related to the symptoms, the latter must show ameliora- 
tion. 

550 



Aneurysm of the Aorta 

dilatation. The pains were sufficiently severe to demand 
analgesics, and yielded after three weeks rest in bed. 

After three years, the pains recurred and the X-ray 
picture was identical with that of the first examination, 
yet several treatments of concussion to elicit the aortic 
reflex of contraction sufficed to subdue the s3rmptoms. 

Peripheral pains in the thorax and arms simulating 
neuritis without the S3rmptoms of the latter (tenderness 
of the nerves in the implicated region, motor and sensory 
disturbances), suggest an aneurysm. The latter fact is 
illustrated in the case dted on page 575. 

To escape the confusion created by a hybrid anatomico- 
clinical terminology, a compromise may be effected by em- 
ploying the term aortectasis, to designate aneurysm or dila- 
tation of the aorta. Aneurysm of the aorta is by no means 
as infrequent as is currently supposed; on the contrary, the 
percentage of deaths varies from 0.6 per cent, of total mor- 
tality (Emmerich) to 1.49 per cent. (Mailer). 

Death occurs suddenly, as a rule, owing to rupture of 
the sac, and many cases of sudden death referred to other 
conditions, owing to the absence of an autopsy, are often 
caused by an aneurysm. 

Practically three-fourths of all aneurysms are aortic and 
nineteen- twentieths of these are located in the thoracic aorta. 
Of the latter, about 90 per cent, are saccular; from 80 to 90 
per cent, occur in the male, and about 50 per cent, occur 
between the ages of 35 and 50. 

Respecting the etiology of aneurysms, it has been said 
that the victim is usually one who has worshiped at the 
shrine of Venus, Bacchus or Vulcan. In etiology most 
writers ascribe the preponderating rdle to syphilis. The 
latter, as an etiologic factor varies in percentage from 25 
(Klemperer) to 92 per cent. (Rasch). Indeed, Osier affirms 
that an aneurysm in a person of either sex, under the age of 

551 



Spondyloth e r a p y 

thirty, is presumptive evidence of syphilis. Among my own 
patients (60), a syphilitic history was positively established 
in only 20 per cent, of the cases. 

In several instances, where a history of syphilis was 
positive, no Wassermann reaction was obtainable. 
Statistics show that in some of the late lesions of syphilis, 
a reaction may be elicited in only 50 per cent, of the cases. 
The reaction is usually positive in the secondary stage 
of untreated syphilis. 

Whether the reaction is positive or negative, mercurial 
inunctions are nevertheless indicated, although I have 
never observed any benefit from them in my aneurysmal 
cases. 

Mesaortitis. — ^This is a peculiar type of arterio- 
sclerosis associated with aortic insufficiency and aneurysm^ 
and is comparatively frequent in syphilitics, notably in 
young subjects. 

A similar lesion is found in congenital syphilis. Spi- 
rochetes are demonstrable in the lesions. 

Evidence is accumulating to show that aortic insuf- 
ficiency is one of the most frequent causes of syphilis, and 
a positive Wassermann reaction may be elicited in a 
number of patients thus afflicted. 

The Babinski syndrome (inequality of pupils and Ar- 
gyll-Robertson phenomena with aneurysm), suggests 
syphilitic infection and so does the prompt relief afforded 
by potassium iodid, as suggested by Osier. 

Among other factors contributory to the etiology are, 
overv^^ork, traumatism, abuse of alcohol and the infectious 
diseases. 

In the opinion of the writer, the foregoing factors may 
operate by diminishing vagus-tone. In accordance with this 
view-point, the anatomic changes in the aortic-wall may 
be secondary to the primary aortcctasis. In young persons 
the most important etiologic factors are trauma and endo- 

552 



Symptomato logy 

carditis, causing the so-called embolomycotic aneurysms. In 
the latter, bacteria are found in the aneurysmal wall similar 
to those found in endocardial vegetations. 

Symptomatology. — Since the advent of the X-rays and 
exact methods of percussion, the non-recognition of an 
aneurysm is an unpardonable error in diagnosis. The sub- 
jective symptoms are essentially pressure-symptoms and vary 
with the degree and location of the dilatation. 

Among the symptoms may be mentioned: 

1. Pain in the sternum, ribs or the spine from direct 
pressure; surrounding the upper-chest, from pressure on the 
intercostal nerves; radiating down the side of the chest and 
the inner surface of the arm, from pressure on fibers dis- 
tributed by the intercosto-humeral nerve. 

2. Dyspnea. — Caused by irritation of the recurrent 
nerve (aphonia, hoarseness and a metallic cough), tracheal, 
bronchial or pulmonary pressure. Dyspnea may be parox- 
ysmal and suggests asthma. 

3. Cough. — ^A frequent early sign, of a peculiar wheezy, 
brazen or metallic character ("goose-cough'*). Cough is 
caused by pressure on the vagus, recurrent laryngeal nerve, 
compression of the trachea or a main bronchus. Pressure 
on either of the two latter structures is associated with 
stridor and expectoration. Cough and dyspnea are out of 
proportion to the physical signs. The symptoms may sug- 
gest phthisis (aneurysmal phthisis). 

4. Dysphagia. — Caused by spasm or stenosis of the 
esophagus. 

5. Hemorrhage. — Caused by tracheal granulations at 
the point of compression, rupture into the bronchial tree or 
from erosion or perforation of the lung. Bleeding may be 
sudden, profuse and fatal, or recurrent for months. 

6. Emaciation. — From pressure on the thoracic duct. 

553 



The author wishes to emphasize the fact that the 
symptoms are often paroxysmal, for the reason that the 
aorta is not constant in caliber; a temporary increase of 
dilatation may precipitate a group of symptoms which dis- 
appear when the lumen of the vessel is restored, 

Fig. 122 shows the relation of the aorta to adjacent 
structures and is explanatory of aneurysmal symptomatology. 




Fig. t7i. — Contents of the mediaatina viewed from the rear, 
applied Anatomy, J. B. Lippiacott Co., publiahera). 

Objective symptoms. — i. Percussion shock. — Direct 
percussion over an aneurysmal area elicits a shock not unlike 
that felt when a rubber-bag filled with water is simultaneously 
palpated and percussed (semi-fluctuation). This sign, ori- 
ginal with Smith, was detected in 6z per cent, of his cases, 
whereas the tug, to be described presently, was present in 
only 46 per cent, of his cases. Grasping the cricoid car- 
tilage for eliciting the following sign (tugging) while an 
assistant percusses the chest, a direct and resilient shock is 
felt when an aneurysmal area is reached. Normal chest- 
areas reveal to the fingers at the cricoid cartilage only a 
distant feeble jar. 

554 



i 



Objective Symptoms 

2. Tracheal tug. — This sign of Oliver is as follows: 
With patient standing with closed mouth and elevated chin, 
grasp cricoid cartilage between finger and thumb and lift it. 
A tug, most marked in inspiration and transmitted to the 
fingers, is supposed to be diagnostic of aortectasis. The 
latter is not correct, insomuch as it is found in conditions 
which cause adhesions between the aorta and air-passages. 
It is not infrequent in tuberculosis, pleuritis, mediastinal 
tumors, enlarged bronchial glands and in enteroptosis, when 
the heart descends with the liver, and the arch of the aorta in 
this way makes traction upon the bronchi. The author finds 
that this symptom is best elicited at the end of a forced inspir- 
ation. 

3. Inspection. — Dilatation of the veins of the neck, 
chest and arms. Diffused arterial pulsations of the carotids 
and subclavians. Pulsation in the first and second inter- 
spaces. To detect latter, patient must be in recumbent 
posture in a good light and the observer's eyes should be on 
a level with the chest, which must be viewed in diflFerent 
directions. Inspection of the patient's back for pulsations 
is equally important. Swelling and edema of the right arm 
may be present from pressure on the subclavian vein and, 
on the front of the chest, from pressure on the internal mam- 
mary, azygos or hemiazygos veins. The larynx may be 
pulled downward and displaced to one side. 

4. Palpation. — In some cases, the aorta can be palpated 
in the epistemal notch and a lift of the manubrium can be 
felt. Over the dilatation, one may feel a diastolic shock or 
a systolic thrill or both. Differences in the radial pulse 
are so frequent, even in the norm, that little importance 
can be attached to changes in the radial pulse on both 
sides. 

The author wishes to direct attention to a new sign in 

555 



S p n d y I 



h 



thoracic aneurysms, viz., extreme sensitiveness of the va, 
to palpation on one or the other side of the neck. 

As a rule, the most tender points are located where t 
recurrent laryngeal nerve enters the larynx behind 
articulation of the inferior comu of the thyroid cartilage with 
the cricoid, and at a point between the hyoid bone 
and the ala of the thyroid cartilage, where the internal 
branch of the superior laryngeal nerve pierces the thyrohyoid 
membrane. The latter is the sensory nerve for the interiof.^ 
of the larynx and trachea. 

.\n absence of pulsation in the femoral arteries may 1 
noted in abdominal aneurysms, due to the fact, as Osier 
suggests, that the sac acts as a reser\'oir, annihilating the 
ventricular systole, thus converting the intermittent into \ 
continuous stream. 

5. AuuxdUxiion. — Accentuation of the second aorl 
tone, a systolic murmur and a diastolic murmur, if aortf" 
insufficiency accompanies the aortic dilatation. An accen- 
tuated metallic second sound over the sac of the aneurj-sm. 
An important sign is either the disappearance or modifi- 
cation of the murmur, if present, after concussion-treatment 
of the seventh cervical spine (page 525). 

Drummond refers to a systolic murmur heard in the 
trachea or at the open mouth of the patient. Respiration 
may be feeble or absent in some part of the lung, owing to 
pressure of the dilated aorta (I'lrfe report of case on page575). 

6. Percussion. — This is one of the most important sigi 
if executed according to the methods suggested by ' 
author. Percussion should be made during the time ' 
chest in in the position oi forced expiration. A number of 
measurements made by the author show that, during the 
latter phase of respiration, the sagittal diameter of the chest 
approximates the arch of the aorta from .3 to 1.6 cm. Afte 

SS6 



b 



J e c £ t V e 



y m p t m s 



this manner, the clicitation of substernal dulness is facilitated 
(page 254). Vibrosuppression (page 80) may be required. 
The author now finds that the e!i citation of the aortic reflex 
of dilatation (page 255) is no longer necessary when the arch 
is to be delimited. Here, the aim was to accentuate dulness 
of the aorta by increasing its caliber. Either of the two 
following methods, preferably the first, may be employed. 




this figure a 
Medicine). 



—Normal boundaries of the heart and great vcssf-ls. The nipples in 
loo far away from Itie median line(Btit]er'5 Diagnostics of Internal 



The SUPRACABDIAC Vasculah Area Containing the 
aorta and pulmonary artery, may be represented by 
drawing a horizontal line across the base of the heart 
(} inch below the upper border of the manubrium, the 
so-called episternal notch), and two vertical lines ex- 
tending on either side of the sternum, from the base of the 
heart to about the lower border of the tst rib. 

The Ascending Aorta lies behind the sternum be- 
tween the third left chrondrostemal junction and the 
second right costal or aortic cartilage. The latter point 
557 



Spondylotherapy 

represents the commencement of the Aortic Arch, 
which nms obliquely upward and backward toward the 
4th dorsal vertebra, where it continues as the descending 
thoracic aorta. 

The highest point of the aortic arch in the median 
line is at about the center of the manubrium (about i 
inch or 2.5 cm. below the epistemal notch). 

The Pulmonary Artery traverses the left sternal 
border imder the 2nd intercostal space and the 2nd costal 
cartilage. 

The arch of the aorta terminates at a point in the back 
to the left of the third dorsal vertebra, at which point the 
bifurcation of the trachea occurs. 

Vagus-tone method. — ^The aortic tone is under the 
influence of the vagus, and v^hen the latter is increased, per- 
cussion of the thoracic aorta is abetted. During percussion, 
pressure may be made at the 7th cervical spine by an assist- 
ant, or, better still, the head of the patient is placed in a 
position of forcible extension (page 228). 

I must again emphasize the importance of palpatory 
percussion^ i, e., to determine dulness by the sense of resist- 
ance. In other words, to disregard the audible quality of 
the percussion-sound. 

Direct percussion of the vertebral spines (3d to 6th dorsal 
spines) may reveal the dulness of an aneurysm {vide, verte- 
bral concussion, page 79). 

Fig. 124 shows the normal percussion-zones of the spine. 

Postural method. — ^When the patient stands on an ele- 
vation (Fig. 125), and stoops far forward, the course of the 
aortic arch may be easily defined by percussion. In both 
methods, forcible percussion must be used. The measure- 
ments of the aorta in the norm have been described on page 

255- 

The fact that, a supposititious area of dulness due to an 

558 



D 



Z 



aneurysm may be diminished or increased in area by the 
elicitation of the aortic reflexes, may be utilized in diagnosis. 
Dam-sign. — By this new phenomenon, I refer to an in- 
crease in the area of aneurysmal dulness (of the thoracic or 
abdominal aorta), when the legs are forcibly flexed on the 
thighs and the latter on the abdomen. Compression of the 
abdominal aorta or an India rabber tube applied after the 



FlO. 134. — Norniftl perti 




spine (Kordnyi, Da CoBta). 



method of Mombui^ for hemostasis will yield the same re- 
sult. By any of the preceding maneuvers, the blood is 
increased in quantity in the aneurysmal sac and distends it. 

Aside from the latter maneuvers and the aortic reflexes, 
the area of aneurysmal dulness is diminished when the skin 
corresponding to the latter is irritated or when the tone of 
the vagus is increased by the method shown in Fig. 65. 

During the period of forced inspiration the diameter of 
559 



S P 



I 



an aneurysm is increased and decreased during a forced 
expiration. During the former, tlie intrathoracic blood- 
vessels are filled, and during expiration, they are relatively 
empty (aspiration action of the thorax). 




Lting the postuial method of determining the ci 
a by percussion. 



AoscuLTATOBY PERCUSSION. — Percussion of aneur- 
ysms, as well as the solid viscera, may be facilitated by 
two methods of the author described elsewhere* in 
detail: 

I. If, during percussion, a stethoscope is allowed to 
hang from the ears of the physician (no part of the instru- 
ment being in contact with the chest of the patient) , 
nuances in the percussion -sound, unrecognizable by un- 
assisted audition, are demonstrable. Here the stetho- 
scope is employed as a microphone. 

560 



Fluoroscopy o f t h e Aorta 

2. By employing !he principle of transsonance. With 
the finger, strike directly the 7th cervical spine, and while 
so doing, gradually approach the site of aneurysmal 
dulness. When the outer boundary of the latter is at- 
tained, the transmitted resonance is 00 longer in evidence. 




Fig. i26.^Rig(n anlerior oblique posilion. A, clear area, corresponding 10 
righl lung; B, shadow o( vertebral column; C, clear middle space; D, shadow of 

normal heart and aona; E, clear area corresponding lo left lung. , dilated 

aorta; , small commencing aneurysm, — . — . — , upper part, larger aneurysm; 

—.—.—, lower part, position of dilated auricle. 

7. Fluoroscopy of the aorta. — Radio-diagnosis may 
be achieved by fluoroscopy and skiagraphy. In the former 
method, which we wIU alone consider, the aorta traversed 
by the rays is directly examined by the fluorescent screen. 
With a large screen covered with glass the aorta may be out- 
lined on the latter by means of a pencil, such as is used in 
writing on glass. In the early history of radio-diagnosis, 
thoracic aneurysms were diagnosed more frequently than in 
the present state of our advanced knowledge. Thus, Sailer 
and Pfahler, have demonstrated that tortuosity of the aorta 
561 



Spondylotherapy 

in arteriosclerosis strongly suggests aneurysm on fluoroscopic 
examination. Many errors are now obviated by an X-ray 
examination in the right anterior oblique position; the rays 
are made to penetrate the chest obliquely at an angle of 45 
degrees from behind forward and from left to right; the 
screen is in front and to the right and the tube behind and to 
the left. In this position, the aortic shadow with parallel 
sides is observed throughout its entire length, and termi- 
nates in a rounded extremity at a point corresponding to the 
level of the stemo-clavicular articulations and the third 
dorsal vertebra. The picture presented in this position is 
illustrated (Fig. 126) after Holzknecht. 

Reference must also be made to the accompanying illus- 
tration (Fig. 127). No. I illustrates the normal aorta in the 
antero-posterior examination; the parallel lines show the 
central opacity, and the part shaded, the aorta, which ex- 
tends to one side of the central opacity. In No. 2 an examina- 
tion of the normal aorta, conducted in the right anterior 
oblique position, shows the vertebral shadow, represented 
by the parallel lines, and the shaded part, the aorta. No. 3 
is the aorta examined in the ordinary antero-posterior posi- 
tion, and the supposition would be that an aneurysmal sac 
is present, but if the patient assumes the right anterior ob- 
lique position, the sac is no longer evident (No. 4), but the 
aortic shadow is broader and retains its parallel borders, 
hence aortic dilatation and not aneurysm exists. Nos. 5 and 

6 illustrate an aneurysm, and 7 and 8 a small aneurysm 
arising from the under surface of the arch. Note that in Nos. 

7 and 8 there is nothing in the pictures to indicate that an 
aneurysm exists; in fact, the appearance differs in no wise 
from the normal (Nos. i and 2). In all examinations for a 
suspected aneurysm the tube should be placed in all posi- 
tions. 

5b2 



Fluoroscopy o f t h e^ Aorta 

The shadow of an aneurysm is more pronounced, the 
greater the amount of organized clot. If the shadow is 
situated to the right of the central opacity and nearer the 
front than the back of the chest, the ascending aorta is in- 
volved; but if the shadow is projected to the left and nearer 



B III # I II 
# I .» » I il 



Fic. 137. — Radiosmpic examination of the aorta, after Hotiknecht (i-tde 
description in the text). 



the back than the front, the descending aorta is probably 
involved. The depth of the aneurysmal sac from the surface 
may be approximately determined on the principle that the 
nearer the sac is to the surfjice, the more defined will be the 
outlines and the less intensified the shadow. Hence, in 
rotating the patient and examining the shadow anteriorly 
and posteriorly, it is presumably nearer that surface where 
563 



S p 



n d y I Q t h 



the shadow Is the smaller and more clearly defined. The 
course of the aneurysm during treatment may be followed 
if at the primary examination a record is made by means of 
the orthodiagraph. Pulsations of a shadow argue for an 
aneurj-sm, but the latter does not always show pulsation; 
in fact, a dilated aorta may show more forcible pulsations 
than an aneurj'sm. When pulsations are absent, the inhj 
tion of amyl nitrite, as I have frequently demonstrated, 
bring them into existence. Neoplasms may show a coi 
municatcd pulsation from the heart or the blood-vessels. 

In the usual examination with the tube in the ceni 
behind the patient, one observes only the bend of the aoi 
projecting to the left of the sternum beneath the claviclej 
whereas the ascending and descending portions cannot be 
seen. In dilatation of the aorta, the shadow extends either 
to the right or left of the sternum or both, and it persists be- 
tween pulsations. In neurotic individuals and when the 
aorta is dislocated (a condition which I shall call aortoplosis) 
in enteroptosis, a shadow extending beyond the sle-num 
may suggest aneurysm, but as a rule, between pulsations, 
the shadow recedes behind the sternum. In aneurysms of 
the innominak, there Is a clear space (with a narrow shadom 
of the artery) between the latter and the aortic shadow 

In differentiating the shadows of structures (glands, 
tumors, etc.) from aneurysms, the former may rotate upon 
their axes, but they do not show the expansion of aneurysms 
during systole and their contraction during diastole, 
invaluable aid is furnished by the clicitatlon of the aoi 
reflexes during the fluoroscopic examination (vide 
of case on page 575). 

I have found that an aneurysm, like the heart, respoi 
by contracting when the skin over the aneurysm is irrital 
564 




Aneurysm of the Pulmonary Artery 

hence cutaneous irritation is of no value in differentiating 
the silhouette of the heart from an aneurysm. 

Among other signs of thoracic aneurysm may be men- 
tioned : inequality of the pupils (anisocoria) due to pressure 
upon the sympathetic or alterations in the circulation, delay 
and inequality of the radial pulses, pain and persistent 
numbness in the shoulder and arm, signs of arteriosclerosis 
(thickening of the palpable arteries) and abatement of 
symptoms after a single seance of concussion applied to the 
seventh cervical spine. 




Fic. ti%. — Percussion-areas of an aneurysm of Ihe abdominal aorta Ken in 
consultation with Dr. Visscher. A, area of aneuiysmal dullness by percussion; 
B and C, aorta refkxes of dilatation and contiactbn. Reduced. Compare with 
Fig. 72. 

Broncho-esophagoscopy may show tracheal compression 
and pulsation or a pulsatile tumor implicating the esophageal 
wall. 

Aneurysm of the pulmonary artery. — Aneurysms of 

this vessel are comparatively very rare. The symptoms 

(dyspnea, cyanosis, cough, bloody expectoration, murmur 

n second left inter-space, etc.) may suggest congenital heart 

S6S 



S p 



y I 



t h 



disease. An X-ray examination furnishes the most trust-J 
worthy evidence, although the affection is rarely interpreta 
inlra vilam. 

Aneurysm of the abdominal aorta. — This is rela- 
tively frequent (10-14 per cent, of aneurysms), and trauma 
plays an important rble in etiology. The aneurysmal sac is 
located most often just below the diaphragm in juxtapositionB 
to the celiac axis. 




FlC. 119. — Apparatus (or t.i^Jn^ \.i.^- ...^ ..■■■.,. IlijI aorla. Thi 

utions are conveyed by a caidiugraph lo a registennR lanibour. 

The subjective signs are: neuralgic abdominal painsl 
radiating in every possible direction and suggesting r 
calculi, gastric ulcer and other affections. 

The objective signs are: expansile pulsation of an epi-] 
gastric tumor, over which a thrill may be felt or a systolic I 
murmur may be heard, retardation and inequality of thel 
femoral pulses, an area of dulness influenced by the aortic 
reflexes (Figs. 73, 73 and 128) and an X-ray examination. 
The latter may be made with the fluoroscopc after the 
patient has l«en freely purged for several days and lim-. 
ited to a diet of milk. Inflation of the colon with air and 
the use of a "compression -diaphragm" aid the fluoroscopics 
diagnosis. 



A neurysm of the A bdominal A orta 

It is the usual practice of the author to make tracings 
of the abdominal aorta (aortograms) as aids in diagnosis. 
They are made with the same ease as sphygmograms of 
the radial artery. The patient is placed in the recumbent 
posture, and, at the end of a forced expiration, during the 
time breathing is suspended, the cardiograph is placed 
over the abdominal aorta. The apparatus is shown in 
Fig. 129. 



A iWWMAM 




Fig. 130. — A, normal aortogram; B, aortogram of abdominal arterioscleiosb; 
C, aortogram of an aneurysm of the abdominal aorta (Fig. 128) 

The course of the abdominal aorta is determined by a 
line (aortic line) drawn from the ensif orm cartilage (to the 
left of the linea alba) to the level of the highest part of 
the iliac crest. At the latter point (J inch below the 
navel), the aorta divides into the two common iliac 
arteries. 

The Celiac Axis is located on the aortic line about 
4 or 5 inches (10 or 12.5 cm.) above the navel. 

On the back, the aortic orifice in the diaphragm cor- 
responds to the 12th dorsal vertebra, and the celiac axis 
to the lower border of this vertebra. 

Abdominal arteriosclerosis. — Paroxysmal pains due 
to this affection are diagnosed with difficulty by the conven- 
tional methods (page 266). Here, pathognomonic aorto- 
grams may be taken. 

567 



Spondylotherapy 

I have noted that when the cardiograph compressed the 
abdominal aorta, some of the abdominal arteriosclerotics 
suffered from their characteristic pains. 

What I did by the latter maneuver was to produce an 
ischemia, thus accounting for the phenomenon of claudica- 
tion (page 226). Compression of the abdominal aorta to 
obliteration with the fingers may therefore be utilized as a 
new objective sign of abdominal arteriosclerosis. 

In enteroptosis with loose peritoneal moorings of the 
aorta (aortoptosis), in neurasthenic women and in arterio- 
sclerosis of the abdominal aorta, a ^Hhrobbing aortd*^ may 
suggest aneurysm of the vessel. Here, there is no definite 
tumor and no expansile pulsation. Tumors in the abdomen 
may show a communicated aortic pulsation, but the latter 
usually disappears in the knee-elbow position. 

TREATMENT OF ANEURYSMS. 

Nothing can be added to the method of cure suggested 
on page 257 e/ seq. 

The author has reported in The British Medical Jour- 
nal (July 8, 191 1), and in La Presse MMicale (Oct. 4, 
191 1), forty cases in his own practice of thoracicand abdom- 
inal aneurysms which were symptomatically cured within 
a few weeks by the concussion-treatment with absolutely no 
other adjuvant measures (not even rest). 

Since then, seven other cases were treated with the same 
results. 

The cases were all advanced and there was absolutely no 
break in the continuity of successful results. 

Some of the author's cases were seen after four years with 
absolutely no recurrence of symptoms. 

It is only just that I should advert to several patients in 
whom minor symptoms (a slight cough, dyspnea on exertion 

568 



Treatment of Aneurysms 

and an inability to assume the recumbent posture) per- 
sisted. 

"Nothing ever gets quite well." The author's treatment 
of aneurysm does not and cannot eliminate the aneurysmal 
sac, although it is somewhat reduced in dimensions. 

It is impossible to conceive of a large intrathoracic in- 
tumescence without some mechanic disturbances incident 
thereto. 

For the latter reason, the author advisedly refers to his 
results as "symptomatic cures." 

Failures by others to elicit results could always be at- 
tributed to mistreatment (page 473). 

The incurability of aortic aneurysms has been for eons 
such an id6e fixe, that it has graduated into an obsess- 
ion. 

Probably the most brilliant achievement of Spondylo- 
therapy consists in the diagnosis and cure of aortic aneurysms. 
Most men will agree that the cure of aneurysms should be 
considered one of the greatest contributions ever made to 
scientific medicine. But such is the cautiousness of medical 
minds that few reviewers of Spondylotherapy have had the 
faith or the courage to speak of this, its greatest achievement. 
Yet, nothing in medicine is now more completely proven, 
and nothing can be more easily demonstrated, than that 
Spondylotherapy can and does cure this heretofore incurable 
disease. 

The treatment in question is practically a specific. I 
have the reports of 12 cases (in addition to my own), from 
other physicians whose results practically tally with my own, 
despite the fact that only primitive apparatus was employed 
in the elicitation of the aortic reflex of contraction. The 
following case, reported ^ by Dr. L. St. John Hely, of Madera, 
California, is cited for the following reasons: the disease was 

569 



S p 



n d y i 



t h 



very advanced, the relief was practically immediate and the 
primitive method shown in Fig. 2 was used. 

This same patient was seen after eighteen months ab 
whom Dr. Hely reports as follows: 

"I am enclosing you three photographs of the patient 
John Artmann, whose case was tteated 18 months ago. He 
came into my ofFice yesterday and his condition is absolutely J 
normal. It was so wonderful that I got out my camera an 
made these pictures. There are no pulsations, nor feelin 
of pulsations at all in the tumor and holding the hand c 
tumor after climbing the stairs conveys no suggestion wh 
ever of pulsations. Facies normal." 

Dr. Hely, reported another case with "the same brillia 
results." 

Report of Dr. Hely; 

"The writer presents the following history of a patient 
suffering from aneurysm of the thoradc aorta who was 
treated by the 'concussion -method' of Abrams: 

"J. A., age 46 years; weight, 185 pounds; a blacksmith 
and a moderate drinker; had no previous history of illness 
beyond the diseases of childhood. On the sixth of No- 
vember, 1909, the patient first noticed a small projection 
in the region of the first rib about the size of a dime. K 
peculiar burning sensation corresponding to the latter 
point was likewise noted, but the patient gave it no serious 
consideration until December 19 of that year, when 
while assisting in lifting a wagon he experienced a chok- 
ing feeling and the miniature projection attained an enor- 
mous size. The patient then sought medical counsel and 
the diagnosis of a thoracic aneurysm was definitely estab- 
lished. At this time the following subjective and objec- 
tive symptoms were noted: 

"Pronounced cyanosis which was universal, cardiac 

palpitation, choking, and dyspnea upon the slightest 

exertion, and an almost incessant cough. At night the 

patient could find a modicum of relief only in one posi- 

570 



e n t of A n e u r y r0'f' 

lion, viz., propped at an angle of 45° on the righl side, 
and even then the coughing and choking would awaken 
him every hour. I regarded his condition as absolutely 
hopeless and so informed his friends. Having at this 
time read of the method of Abrams, I employed it first 
on January 21, 1910. Concussion treatment of the 
seventh cervical vertebral spine was executed daily for 




in Dr. L. St, John Ilcly's i.asr of aneurysm 



fifteen minutes from the latter date until March 5, 1910, 
when treatment was discontinued. 

"The second night following the concussion the patient 
rested well, and after the fourth treatment there was an 
absolute evanescence of all symptoms. In the language of 
the patient, "1 can now sleep in any position and Uke a 
baby; in fact, as natural as any one. I do not cough nor 
suffocate any more, ami. asifle from the tumor on the 
571 



Spondylotherapy 

chest, I would not know that there was anything at all 
the matter with me." 

"The aneurysmal tumor when first examined projected 
considerably and measured about 2^ inches in diameter 
at the base. At the end of the first week's treatment the 
tumor was reduced about 25 per cent, but there was no 
apparent further diminution in size when treatment was 
discontinued. It was impossible for me to continue 
treatment, as the patient insisted that he was well and 
further treatment was unnecessary. The results in this 
case were, however, immediate and corresponded in the 
main with the results obtained in the cases reported by 
Dr. Abrams." 

Two other reported cures were made by Dr. L. C. 
Boyd of Long Beach {New York Medical Journal, Oct. 
21, 1911) and Dr. M. L. Tumbull, of San Francisco 
(Medical Record, Sept. 9, 191 1). 

Dr. L. C. Boyd reports as follows: 

"In the British Medical Journal (July 8, 191 1), Dr. 
Albert Abrams, of San Francisco, reports forty cases of 
aneurysm of the thoracic and abdominal aorta treated 
by his method of concussion of the seventh cervical spine. 
His method is practically a specific in a disease which 
has heretofore baffled our best efforts, and it creates an 
epoch in therapeutic medicine and elevates physiologic 
therapeutics to a place of distinction in the armamenta- 
rium of the physician. 

"Mrs. H., age, 31. Duration of symptoms, three 
years. 

''Subjective Symptoms. — Precordial pain, radiating 
to head and left arm. The painful paroxysms were accom- 
panied by great prostration. Dyspnea was constant and 
like the pain was accentuated by exertion, emotions or 
high altitude. 

"There was a troublesome dysphagia, insomnia and 
dysphonia. 

"Objective Symptoms. — Moderate exophthalmos, 

572 



Subjective Symptoms 

vasctilar engorgement of face, neck and hands (notably 
on the left side). 

"The right radial ptilse was retarded and weakened. 

'There was a slight bulging of the anterior chest-wall 
corresponding to the first and second intercostal spaces on 
the left side and a marked area of dulness on percussion. 

"The latter dulness could be made to contract or en- 
large in area at will by elidtation of the aortic reflexes. 
(This is an important diagnostic aid in differentiating 
the dulness of aneurysms from the dulness of other 
causes.) 

"Palpation yielded a slight systolic thrill over the area 
of aneurysmal dulness. 

"A loud systolic bruit was heard over the aneurysmal 
dulness which was propagated posteriorly along the 
course of the descending aorta. 

"There was an accentuated second aortic tone. 

"The heart was somewhat displaced to the left and 
the apex beat was diffused over a large area and dimin- 
ished in force. 

"Slight tracheal tugging was present. 

"Treatment was administered twice daily and com- 
menced on July 2, 191 1, and continued imtil the 17th of 
the same month. 

"The following notes are based on an examination 
made on Aug. 8, 191 1. 

"Subjective Symptoms. — ^Absolutely no pains of any 
kind. Dyspnea, dysphagia and insomnia have disap- 
peared. The voice is practically restored and the patient 
expresses herself as being highly gratified with the com- 
plete relief from previous agonizing physical suffering 
which this treatment has afforded. 

"Objective Symptoms. — No exophthalmos nor vascu- 
lar engorgement of the head and extremities. 

"Right radial pulse no longer retarded and restored 
to the norm. 

"The bulging of the anterior chest-wall is still present, 
but diminished. 

573 



S p 



ndylotherapy 



''The former aneurysmal area of dulness is fairly 
nant but not completely so. The latter may be attributed 
to the induration of the chest-wall contiguous to the site 
of the aneur3rsm. 

''There is no longer any accentuation of the second 
aortic tone. 

"The systolic thrill and bruit have disappeared. 

"The apex beat is not diffused but circumscribed ajid 
has regained its normal position. 

"Tracheal tugging persists. 

"Improvement in strength and genend appearance of 
well-being still continues. 

"There was no X-ray verification of the conditions in 
this case, but the physical signs respecting the aneurysm 
and the results of treatment were absolutely positive and 
unmistakable.'' 

Dr. M. L. Tumbull, presents the following: 

"The report of tfcle following patient, I believe to be 
indicated, for the reason that we have heretofore regarded 
aneurysms of the aorta among the incurable diseases. 

"A. D., age, 28 years. Sent to California by his phy- 
sicians in Chicago for supposed pulmonary tuberculosis. 

"Seven years ago contracted s)rphilis. Entered the 
service of Dr. W. C. Voorsanger, at the Mount Zion 
Hospital, for dyspnea, pains in the chest and a constant 
cough and expectoration which permitted him no sleep 
at night without the use of narcotics. Slight dysphonia. 
Veins of the neck very prominent and dilated. Slight 
tracheal tugging. 

"Pronounced dulness on percussion of the upper chest 
corresponding to the arch of the aorta, which measures 
6 cm. in diameter. 

"Systolic murmur over aorta propagated toward the 
left shoulder. 

"Palpation reveals a diastolic shock over the region 
corresponding to the orifice of the pulmonary artery. 

"A skiagraph shows an immense aneurysm of the 
thoracic aorta, chiefly implicating the arch. 

574 



Comments by the Author 

"Examination of the sputa, negative. 

"A vigorous course of inunctions was without effect 
on the symptoms. 

''At this time the patient presented an anemic appear- 
ance and his weight was ii8 pounds. 

"Treatment by concussion daily of the 7th cervical 
spine was commenced on April 26, 191 1. After the first 
stance of concussion, lasting ten minutes, the systolic 
murmur over the aorta almost disappeared. 

"On April 29, the aneurysmal dulness measures trans- 
versely 2.6 cm. 

"May I, 191 1, aneurysm measures 2 cm. and the 
patient's weight is 123 pounds. 

"May 3, 191 1, absolutely no dulness over site of aneur- 
ysm, pains in chest gone, expectoration reduced about 
50 per cent, but cough continues with less frequency 
and severity. 

"July I, 191 1. Patient's weight is now 135 pounds. 
Has absolutely no symptom beyond an occasional cough, 
which may be attributed to a naso-pharyngeal catarrh.'* 

Comments by the author. — On Nov. 28, 191 1, this 
patient developed a violent cough followed by hemo- 
ptysis. His aneurysmal symptoms were absolutely gone, 
and for this reason search was made for his trouble. 
An apical infiltration was demonstrated with a large 
number of tubercle bacilli in his sputum. Previous ex- 
aminations of his lungs and sputa were negative. 

The following anamnesis is extremely interesting in illus- 
trating discordant views among the leading medical authorities, 
coupled with the fact that, the execution of a simple diag- 
nostic sign would have clarified a bizarre and protean clinical 
picture : 

A prominent attorney suffered for several months in 
San Francisco from periodic paroxysms of coughing, 
which were so violent as to induce attacks of vertigo, 
and narcotics were administered to subdue them. His 

575 



S p 



physicians were unable to trace the genesis of the cough, 
and receiving no relief, he left for Europe for further 
counsel. During his soioum in Europe, he suffered from 
atrocious pains in the chest and the left arm. Some 
ascribed the pains to neurilis, although there was abso- 
lutely no objective evidence of the latter. Repeated 
skiagrams of the chest demonstrated the presence of an 
intrathoracic shadow (Fig. 132), the nalure of which was 
variously interpreted. Kocher.of Bem.afterdeliberating 
a week concerning his findings concluded that, the pa- 
tient was the victim of a spinal growth and that a serious 
and immediate operation was necessary. 




Fig. 131. — Intrathoiacii. sliuiJu' 
growth (vide text J. 

The patient almost concluded to submit to an opera- 
tion, but before so doing, he consulted Sabli of Bern. 
The latter assured him that he could find no growth and 
prescribed quinin, which caused the pains (which had 
previously resisted narcotics) to evanesce. 

The patient was subsequently examined by at least 
twelve of the leading authorities of Europe, all of whom 
gave varying opinions. On the return of the patient to 
this city, the paroxysms of cough continued with una- 
bated severity. 

My examination in brief, revealed the following; 

1. Dilatation of the arch of the aorta on percussion; 

576 



Comments by the Author 

2. Slight tracheal tugging; 

3. Induration and infiamation of the vocal cords and 
a slight arytenoid paralysis; 

4. Absence of respiratory sounds over the lower lobe 
of the right lung; 

5. On fluoroscopic examination, a shadow was seen, 
which was somewhat fusiform in contour and approxi- 
mated the spine. 

Comments by the author. — The possession of an X-ray 
apparatus does no more in postulating a knowledge of 
skiascopy than the possession of a microscope of microscopy 
The errors perpetrated by the microscopist are no less grave 
than those of the skiascopist. The proper interpretation of 
an X-ray examination, coupled with correct technic, means 
essentially a study of chiaroscuro, or of light and shadow 
effects. An X-ray examination is practically an autopsy con- 
ducted on the living and misinterpretation may make a 
verity of a metaphor. If the aortic reflexes had been elicited 
during the fluoroscopic examination, an error in diagnosis 
would have been practically impossible^ insomuch as the con- 
traction and dilatation of the shadow would have demon- 
strated its association with the aorta. 

The fact that, the respiratory soimds over the lower lobe 
of the right lung were again audible after a brief stance of 
concussion of the seventh cervical spine, was in itself a 
demonstration that, the treatment contracted a dilated aorta 
and thus temporarily eliminated a mechanic bronchostenosis 
which accounted for the absent vesicular murmur. 

The paroxysmal symptoms of the patient suggested an 
aneurysm, insomuch as we know that the lumen of the aorta 
is not constant and is subjected to periodic fluctuations from 
a variety of causes (page 620). 

The fact that the pains were primarily relieved by quinin, 

577 



S p n d y I 



t h 



p y 



only emphasizes the importance of this medicament in in- 
creasing vagus-tone and thus diminishing the caliber of the 
aorta which by pressure caused the pains from wliich the 
patient suffered. Two weeks daily concussion of the seventh 
cervical spine practically subdued the violent paroxysms of 
coughing and the larynx wjls almost restored to normal. 

The author finds that fusiform aortic dilatations are less 
amenable to rapid results from concussion than are the sac- 
cular dilatations. 

Dr. W. T. Baird, a prominent physician of E! Paso, 
Texas, presents the following autobiography of his case 
(reported in the Medical Record): 



Aneurysm of the iknoiunate artery. — "Dr. W. T. 
Baird. Age, almost 80 years. Practiced medicine con- 
tinuously for 47 yearSf during 8 years of which time I 
was A. A. Surgeon in the U. S. army. Had la grippe in 
1888, and since this time have suffered from cardiac 
arrhythmia. During the last 5 years I have experienced 
almost constant coldness and numbness in my left leg. 
About one year ago, pains of a peculiar sickening and 
prostrating character were experienced in the arms and 
chest and they would awakea me at night. About three 
months ago, I felt a pressure on my trachea which 
aflected my voice to the extent of aphonia. Since about 
one year, I first obsen'ed a diSused pulsation in the 
supra-sternal fossa. My pains increasing in severity and 
dyspnea becoming accentuated, I was esamined by Drs. 
Gallagher, Brown, Calnan and Fleming, of El Paso, all 
of whom concurred in the diagnosis of an aneurysm. 
I then decided to go to Dr. Albert Abraras, of San Fran- 
cisco, for treatment. I certainly supposed that a phy- 
ddan who had originated a new method of treatment 
for an incurable disease was best qualified to treat it. 

"After my very 6rst treatment, a troublesome and 
persistent cough has never returned. At the commence- 

578 



Aneurysm of the Innominate Artery 

ment of treatment, my voice, which was then only a 
*squeak,' was rapidly restored to normal. 

"After twelve treatments, I observed the following 
relative to my condition: cardiac arrhythmia has dis- 
appeared, coldness and numbness in my left leg are no 
longer present and the pressure on my trachea and the 
air-hunger have disappeared. In fact, I regard myself 
as perfectly restored. At about the end of a week, the 
supra-sternal pulsation was fully reduced 50 per cent." 

Comments by the author. — My examination re- 
vealed dilatation of the aorta, but the arteria innominata 
was chiefly implicated in the angiectasis. 

Painful and deformed fingers due to arthritis deformans 
were almost restored to normal after twelve treatments. 

The results thus attained are given explanation on 
page 402. 

The disappearance of arrhythmia and other circula- 
tory disturbances, can be attributed to myocardial-toning, 
insomuch as the method of treatment (concussion of the 
7th cervical spine), evoked equally the heart and aortic 
reflexes of contraction. 

Pains in the arms from which Dr. Baird has suffered 
for years were caused by an osteo-arthritis of the shoulder 
joints. An ankylosis of the shoulder is not uncommon 
and the adhesions are concealed by the compensatory 
movement of the scapula. Any elevation of the arm be- 
yond the horizontal in the norm is effected by rotation of 
the scapula, hence, in testing the joint fix the scapula. 
Aside from restricted and painful motion in the joint, I 
have foimd that the sensitive points in the course of the 
brachial plexus, are made more sensitive by active and 
passive movements. In inflammation of joints limitation 
of motion is also due to rigid muscles, in conformity with 
the law of Hilton: — ^nerves innervating groups of muscles 
moving a joint also furnish a distribution of nerves to the 
skin over the insertions of the same muscles, and the in- 
terior of the joint receives its nerves from the same source. 

Even an imperceptible ankylosis may show acute exacer- 

579 



S p n d y I o the r a p y 

bations suggesting neuritis, but the absence of definite areas 
of tenderness in the course of the radiating pains excludes 
neuritis. Here, large doses of the salicylates (page 142) are 
effective. 

Dr. Baird noted attacks of intense dyspnea after riding 
in his automobile. After riding in larger machines such 
attacks did not ensue. The back of his seat corresponded 
to the third dorsal spine, which, when concussed en- 
larges the large intrathoracic blood-vessels 

Aneurysm of the thoracic and abdominal aorta 
IN THE SAME SUBJECT. — A gentlemen, 43 years of age, 
sought relief for attacks of pain in the chest and abdo- 
men. Intense dyspnea at night and coughing prevented 
sleep. Lost 50 pounds in weight. Examination revealed 
in brief an aneurysm of the thoracic and abdominal 
aorta. When the patient first came under observation a 
chronic parenchymatous nephritis was demonstrated 
and the symptoms (edema, dyspnea) becoming accentu- 
ated, further treatment of the aneurysms was suspended. 

If percussion of the thoracic aorta, were executed as a 
routine method of examination, a clinical in lieu of an an- 
atomical diagonosis would be more frequent and many 
apparently trivial symptoms could be traced to their real 
source of origin. 

Recently, the author examined an individual whose only 
symptom was an incessant desire to swallow, for which no 
relief was obtained. Examination demonstrated an aneur- 
ysm of the thoracic aorta. 

The non-recognition of an aneurysm is an unpardonable 
error in diagnosis, and the modernist can no longer seek 
refuge for his dereliction in the traditional classification: 
(a) Aneurysms with signs and symptoms. (6) Aneurysms 
with symptoms but no signs, (c) Aneurysms with neither 
symptoms nor signs. 

580 



Rationale of the Authors Method 

Rationale of the author's method. — ^This is essen- 
tially the employment of a reflex in treatment* (page 392). 
The author believes that the cure of aneurysm by his method 
is achieved by increasing the contractility and tonicity of the 
aorta (page 410) and that the impulses are conveyed indirectly 
to the vagus (page 519 and Fig. 119). 

Reduction in the area of an aneurysm as demonstrated 
by numerous skiagrams is never in proportion to the amelior- 
ation of the subjective symptoms. 

Percussion may show an absence of aneurysmal dulness 
in patients symptomatically cured, yet a skiagram reveals 
the aneurysm but only slightly diminished in area. 

In the treatment of his aneurysmal cases, the author 
employed concussion exclusively as a crucial test. Having 
established its specificity, he no longer eschews those adju- 
vant measures which combat aortectasis, viz., inhibition of 
cough by codein, the use of laxatives, anti-luetic treatment 
and a plenitude of physical and mental rest. The influence 
of the latter on aortic tonicity has been shown on page 466. 
One must also remember that an hypodermatic injection of 
pilocarpin (.0065 gm.), will accentuate the aortic reflex of 
contraction (page 457). One may also advise the patient to 
increase vagus-tonicity by forcible extension of the head 
(page 469). Such exercises maybe taken twice a day; thirty 
extensions suflBce for each stance. 

Fig. 1 33, represents the primitive apparatus necessary for 
concussion in the absence of more elaborate apparatus. 
More can be accomplished with an ordinary tack-hammer 
than with the useless apparatus on the market. In fact, with 
the hammer only, cures were effected by other physicians. 

^Dr. H. Jaworski, of Paris, France, designates the methods of the author as verte- 
bral refUoGOtherapy, Reflexotherapy is given extended consideration on page 636. 

581 



Spondylotherapy 

Due regard must be paid to the possible consequences 
when concussion is executed in the treatment of aneur3rsins 
(page 640). 

The sinusoidal current may substitute concussion, when 
the stimulating action of the latter is exhausted (page 4cx>). 




% 




Fig. X33. — Illustrating primitive apparatus for executing concussion. A tack- 
hammer, over the striking end of which is affixed the rubber-tip of a crutch and a 
piece of linoleum or other suitable material over the end of which a piece of rubber- 
tubing b fitted and which is used for pleximetric purposes. 

When patients are hypersensitive to electricity, the author 
employs rubber-cement which is painted on the skin corres- 
ponding to the area occupied by the electrodes. The cement 
must be dry before using the current. 

CocAiN KATAPHORESis. — This is very unsatisfactory, 
and the negative results suggest a very important field 
for research. In my investigations, I found that definite 
cutaneous areas rendered anesthetic by cocain (kata- 
phoretically and by injection) were decidedly more 
sensitive to electric currents than were normal cutaneous 
areas. In hysterical subjects, the author has found that 

582 



c a i n Kataphoresis 

areas of anesthesia peculiar to this disease react similarly. 
There is much reason to believe that nerve-energy is a 
form of electricity and in man there are electric nerves. 
The demonstration of animal electricity galvanometri- 
cally is difficult of demonstration, but the foregoing ob- 
servations may suggest a new field of observation, i. e., 
by excluding other cutaneous sensations, the perception 
of electric sensation is demonstrable. After this manner, 
the law of specific nerve-energy (page 545), can be made 
manifest with reference to problematic electric nerves. 



583 



Percussion o f t h e Stomach 

modified and a Roentgenographic examination (individual 
standing) shows the normal forms of the stomach, according 
to Holzknecht and Rieder, as pictured in Fig. 134. 

In the former, with dorso-ventral transillumination in 
standing and the stomach filled with bismuth, the pylorus 
represents the most dependent part of the stomach ; a, cepha- 
lic pole; b, gas-bladder of the pars cardiaca (fundus); d, 
pars media (corpus); e, pars pylorica; c, caudal pole (identi- 
cal with the pylorus). The stomach is the shape of an ox- 
horn. 



HunduM 




'_FiG. 135. — Diagrammatic outline of the stomach (Gray). 

On page 321, the author has described the vago- visceral 
method of outlining the stomach and Fig. 86, is only sche- 
matic. It is now possible to delimit by percussion practically 
the entire stomach excepting the cardiac orifice (Fig. 135). 
The latter is situated at a point on the 7th left costal cartilage, 
one inch (2.5 cm.) from the sternum and corresponds approx- 
imately with the body of the nth dorsal vertebra. Delimi- 
tation of the stomach by the author's method of percussion 
is only possible with the patient standing. 

During the time the gastric walls are made tense by 
pressure in an intercostal space by an assistant (which 
causes reflex stimulation of the vagus), or without an assis- 

585 



S p 



t h 



p 



tant, by having the patient fix his head in forcible hyperex- 
tension, as shown in Fig. 65, the stomach yields a dull tone 
on percussion. The intercostal method may be used in 
children. The latter dulness at once becomes tympanitic 
when either of the two foregoing maneuvers are inhibited. 

During either maneuver, the dulness of the stomach is 
differentiated from the resonance of the lung and the tjin- 
panicity of the intestines. 

Fig. 136 represents a normal stomach outlined by the 
vago-visceral method of percussion j the continuous line 
represents the stomach when empty, and the broken lines 
the position after the ingestion of bismuth; L, represents the 
lower border of the liver. If a comparison is made between 
the X-ray pictures of the stomach (Fig. 134) and those 
obtained by the vago-visceral method of percussion, one 
notes a discrepancy in size and shape of the organ. 

Now, the X-ray pictures have been determined by filling 
the stomach with a bismuth- paste. We note in Fig. 136, 
what ensues respecting the form and position of the organ 
before and after the ingestion of bismuth, and we are con- 
strained to conclude, that the X-ray pictures are artificiat* 
and only partially reproduce the real shape of the organ. 
The moment food is ingested, and particularly bismuth, the 
stomach endeavors to evacuate its contents and the exag- 
gerated vertical posture of the organ is manifested. The 
latter conclusion was only formulated after repeated exam- 
inations of at least one hundred cases. In a small minority 
of instances, notably in severe grades of gastric atony and 
gastroptosis, the vago-visceral method was by no means 
easy, owing to atony of the musculature of the stomach. 



•Stiller,'"' likewiBC protests ii 
al ihc normal stomach. ' 
ingested bismuth. 



ccpting the radiologist's conception of tlie shape 



Percussion of the Stomach 

The fact that, there is no transition from tympany to dulncss 
by augmentation of vagus-tone, may be utilized in estimating 
the tone of the muscular component of the stomach. 




Fig. ij6, — Percussion of Ihc stomach bj- the vago-visteral method (page ^iij. 
The coQlinuous lines represent the empty stomach and the inlernipted lines, the 
contour of the organ after the ingestion of bismuth. L, indicates the loner livet- 

Having delimited the organ by percussion, one may 
easily demonstrate that, concussion of the 5th dorsal spine 
587 



S p n d y I 



P y 



or paravertebral pressure (page 467), will enlarge th^ pylorus 
(dilatation) and that similar maneuvers limited to the 3d 
dorsal spine will contract the pylorus. In other words, we 
elicit the pyloric reflexes of dilatation and contraction.* 

To the average reader, these observations seem incred- 
ible, but they have been most carefully controlled by X-ray 
examinations and in other ways. 

The following simple test may be utilized in determining 
the patency of the pylorus; after careful percussion of the 
upper and lower border of the stomach, the patient ingests 
nine ounces of water and the time is noted when the organ 
passes from the vertical to its normal position. As a rule, 
this occurs in about one minute. 

Paravertebral pressure between the third and fourth dor- 
sal spines, which inhibits vagus-tone (page 472), will maintain 
the vertical posture of the stomach as long as pressure is 
continued. j^g 

Diagnostic data. — Some reference to this subjectraBfl 
made on page 323. ^Q 

In several instances, the writer has made an early diag- 
nosis of a carcinoma of the stomach by noting irregularities 
of the borders of the organ after percussion of the latter. 
Gastrectasis caused by pyloric obstruction may be deter- 
mined by noting the absence of the pyloric reflexes. That 
is to say, percussion by the vago-visceral method shows 
neither an augmented area of the pylorus after concussion 
or pressure at the fifth dorsal spine nor a diminished area, 
after like maneuvers at the third dorsal spine. 



•My meaaurerocTits show that the location of the pylorus in the norm is 8.6 cm. from 
the lower bordei of the costal aich in the pamstemal line. It has a normal 



width by percussion of i 
after the ingestion of g oul 
cloMng nerve for the pylor 
occur simullaneotuly. 



., and descends 2 cm. after a deep insp'iiution ot 

s of water. The dilator nerve of the cardia is • 

Opening of the cardia and pyloric 



ardtospasm 

Perigastric adhesions may be surmised when percussion 
of the stomach shows no descent of the latter during forced 
inspiration. 

An hour-glass stomach was determined in one patient. 

Spasm of the pylorus may be differentiated from hyper- 
trophic stenosis by elicitation of the pyloric reflexes. 

Cardiospasm (contraction of the cardiac orifice) is usu- 
ally associated with esophageal dilatation. Regurgitation of 
food may or may not be present. The food regurgitated is 
not from the stomach. Radiographs show the dilatation and 
esophagoscopic examination demonstrates the presence or 
absence of pathologic conditions. In cardiospasm ofneu- 
rosal origin, pressure between the third and fourth dorsal 
spines by inhibiting vagus-tone (page 467), will enable the 
patient to swallow without difficulty during maintenance of 
pressure. 

In cardiospasm, the stomach tube (30 to 35 French 
scale), is arrested at a point about 8 or 10 inches from the 
teeth. In any obstruction of organic origin small sounds or 
tubes will pass a stenotic orifice more easily than large ones. 
The contrary holds when a spasm is fimctional. The etiol- 
ogy of cardiospasm is obscure. A few cases are associated 
with gross lesions (ulcers, fissures) of the esophagus or 
stomach (carcinoma) and neurasthenia as a factor in etiology 
is no doubt exaggerated. 

If, during the passage of a tube, the latter is obstructed 
owing to a spasm of the esophagus, paravertebral pressure 
between the 3rd and 4th dorsal spines, by releasing the 
spasm, permits of the introduction of the tube. 

Gastroptosis may be differentiated from dilatation of the 
organ by noting the position of the lesser curvature of the 
organ in relation to the greater curvature. In gastroptosis, 
the pylorus and lesser curvature are correspondingly de- 

589 



pressed, whereas in gastrectasis, it is the greater cun'ature 
which is displaced downward. By the author's method of 
percussion, the normal distance between the two curvatures 
is approximately 5 to 8 cm. 

Gall-bladder disease (cholelithiasis and cholecystitis), 
causes adhesions and definite displacement of the stomach 
and duodenum. The evidence of such adhesions has been 
demonstrated fluoroscopically in the upright position. 
Pfahler'°* directs attention to the fact, that the symptoms of 
gall-bladder disease appear during digestion when adhesions 
interfere with the emptying of the gall-bladder, either di- 
rectly or because the gall-duct has been drawn abnormally 
high. 

Vago-visceral percussion of the stomach may be equally 
utilized in diagnosis by noting the approximation of the 
pyloric end of the stomach to the gall-bladder. It is also 
true that adhesions would prevent the vertical posture of 
the stomach after the ingestion of water or food. 

Pharmaco-diagnostic data with relation to the stomach 
have been noted on page 453, and it is well to bear in mind 
the centers in the cord sensorlally related to the stomach 
(page 377). If the third, fourth and fifth dorsal spines are 
thoroughly frozen, all subjective and objective sensations of 
gastric genesis evanesce from minutes to hours. Thus, one 
may differentiate gastric from other affections. Supple- 
mentary to the data on page 453, my observations show 
that, adrenalin dilates and pilocarpin contracts the stomach. 
Thus, 10 minutes after an injection of pilocarpin (gr. A), 
the vertical diameter of the stomach (lesser to greater 
curvature) measured 2 cm., although before, it measured 
5 cm. Ten minutes after an injection of 8 minims of adrena- 
lin chlorid solution {1:1000), the same diameter of a stomac] 
increased from 5.6 cm. to q cm. After this manner one n 



Percussion of the Intestines 

determine whether gastric neuroses are under sympathetic 
or autonomic control. 

The treatment of gastric affections has been discussed on 
page 324. Supplementary to treatment referred to on the 
latter page, a complarison of concussion and slow sinus- 
oidalization is shown by the following results : the duration 
of concussion and sinusoidalization of the second lumbar 
spine was one minute. 

CONCUSSION. 

Degree of stomach reflex of contraction 2.8 cm. 

Duration of stomach reflex of contraction. • . .5 minutes. 

SLOW SINUSOroAL CURRENT. 

Amplitude of stomach reflex of contraction 2 cm. 

Duration of stomach reflex of contraction 11 minutes 

While the amplitude of the reflex was less with the 
current, its duration lasted more than twice the time. 

PERCUSSION OF THE INTESTINES. 

Physiologists are divided concerning intestinal innerva- 
tion. The viscero-motor nerves are derived from the vagi 
and sympathetic chain. 

Clinical physiology, however, sheds some light on the 
subject. The different maneuvers for increasing vagus-tone 
(page 469) do not influence the intestinal reflexes (pages 325, 
326), but the latter cannot be elicited if the vagus-tone is 
removed by pressure between the third and fourth dorsal 
spines (page 467). 

In this regard, the action of the vagus may be compared 
to the brain and cord. Irritation of the latter has no evident 
effect on intestinal movements during life, yet one knows 
that the mentality may influence the movements and that in 
paraplegia, intestinal motility is diminished and tympanites 
ensues. 

591 



Spondyloth e r a p y 

The elicitation of the intestinal reflex of contraction (page 
325), causes a contraction of all the intestines and it is im- 
possible to differentiate individual portions. 

It is now possible, however, to elicit dulness of definite 
intestinal areas by aid of paravertebral pressure with the 
radicularpressor (Fig. 112). Pressure must be maintained 
by an assistant during the time percussion is executed and 
the patient must be standing. In some instances the area 
of the intestine yields an absolute dulness, and in other 
instances it is only tympanitically dull. 

The following pressure sites have been established: 
I. Duodenum. — Pressure on both sides of the 10th 
dorsal spine. The dulness thus elicited averages in width 
4.5 cm., and extends an average distance of 5.5 cm. from 
the pyloric end of the stomach. Unlike the stomach, it is 
uninfluenced by the movements of respiration, and the site 
of the dulness does not change like the stomach by con- 
cussion of the nth dorsal or 2nd lumbar spines. 

2. Sigmoid flexure. — Pressure on both sides of the 

1st dorsal spine, 

3. Cecum with attached ileum? and ascending 
COLON. — Pressure on both sides of the 12th dorsal spine. 
Careful percussion demonstrates an area of dulness attached 
to the cecum averaging 2.5 cm. in width and 3 cm. in length. 
This is possibly a part of the ileum. 

4. Descending colon. — Pressure on both sides of the 
1st lumbar spifie. The average area of dulness is small 
(6 cm. X 6 cm.) and is located above the dulness of the sig- 
moid flexure in the left lumbar region. 

5. Transverse colon. — Pressure on both sides of the 
4th lumbar spine The area of dulness extends across the 
umbilical region from the ascending to the descending colon. 

592 



D 



Its limitation at its upper part is not always clearly defined. 
The width of the dulness averages 4 cm. 




[ .r ii.).-;iln,il liullnf-;^ fli.i(i.-il I'V | Mra vertebral pressure. The 

dulliu--..ii ■■ .; li M ^^,is ikti.riiiiEioil iiv the vaco-vhcetal method (page 3J1), 

D, duodenum; C, cecum; I?, probably anached ileum; DC, descending colon; SF. 
sigmoid flexure; TC, transverse colon, the continuity of which is interrupted in the 
illustration by ihe stomach and duodenum. Compare with Fig. 138. 

Fig. 137, shows the location of the areas of intestinal dul- 
ness elicited by paravertebral pressure at definite spinous 
processes and Fig. 138, shows the normal topography of the 
intestines. 

593 



D iagnosts 

Recently,"^ attention has been devoted to a mobUe 
cecum (coecum mobile), which produces symptoms resem- 
bling appendicitis and at the operating table the appendix 
was normal. The value of topographic percussion in such 
instances is apparent without comment. 

I wish to illustrate some of the foregoing methods by the 
citation of a case seen with Dr. A. Gates, of Los Angeles. 

The patient has lost 20 pounds in weight during the 
past year. Has recurrent attacks of pain for years in the 
epigastrium of a dragging, pierdng character, several 
hours after food is taken, which is relieved by the ingestion 
of more food or sodium bicarbonate. The history sug- 
gests a duodenal nicer. 

Percussion made during the time the head was ex- 
tended (Fig. 65) demonstrated a dilated stomach. Pres- 
sure at the loth dorsal spine elicited the dulness of the 
duodenum. During forced inspiration, the area of gas- 
tric dulness descends showing that there are no perigas- 
tric adhesions. When the patient ingested 9 ounces of 
water (page 588), the stomach remained in the vertical 
position for 10 minutes (i minute in the norm). It was 
then assumed that there was a pyloric obstruction. The 
latter, however, was a spasm of the pylorus^ for when 
pressure was made between the 3rd and 4th dorsal spines 
(which releases gastric spasms, page 589), the stomach at 
once assumed its normal position. The dilatation of the 
stomach it was assumed was likewise caused by the 
spasm and not a mechanic obstruction. Further con- 
firmation of the pyloric spasm was elicited by the fact that 
pressure at the 5th dorsal spine (page 588) caused an in- 
crease in the percussional area of the pylorus. 

Over the area of gastric dulness, a very tender spot 
(i cm. in width) was palpated which shifted upward after 
concussion of the 2nd lumbar spine and downward by 
concussion of the nth dorsal spine and a forced inspira- 
tion. A tender spot of like area was located at the duo- 

595 



Spondylotherapy 

denum but which showed no dislocation on inspiration 
nor concussion. 

Freezing the 3d, 4th and 5th dorsal spines (page 377), 
caused the area of gastric tenderness to disappear but 
did not influence the duodenal point of sensitiveness. 

Diagnosis. — Ulcer of the stomach and duodenum. 

Comment. — The presence of occult blood in the feces 
is a valuable diagnostic point. 

Exclusive rectal feeding (not even water by the mouth) 
causes the s3rmptoms of gastric and duodenal ulcer to 
disappear in a few days and is equally diagnostic. 

Duodenal ulcers are frequently confused with gastric 
ulcer. The former occur usually in early adult life and 
are characterized by periodic attacks of * 'stomach 
trouble." Pain and tenderness usually extend from the 
mid-line to the right and the accentuation of symptoms 
due to ingested food occurs several hours after a meal. 
The so-called "hunger-pain" is a frequent sjrmptom. 

Auscultation of sounds evoked by intestinal peristalsis 
shows that, the sounds are increased in intensity during the 
time pressure is made between the 3d and 4th dorsal spines 
and that they become less loud or are inhibited during the 
time pressure is maintained at the 7th cervical spine. 

THE LIVER. 

The study of visceral anatomy or organology in the 
conventional way in the dissecting room, gives us an inade- 
quate conception of the topographic anatomy of the living 
viscera. This criticism is equally applicable in the arraign- 
ment of the conventional methods of percussion. The lower 
border of the liver may be cited as a paradigm. Percussed in 
the usual way and compared with the author's methods on 
page 598, it will be found that, it is usually 4 cm. lower than 
would be indicated by percussion after the accepted methods 

596 



The Gall-Bladder 

(Fig. 139). Reference to the foregoing observation must be 
recalled in locating the site of the gall-bladder. 

By what the author designates as splanchnoscopy ^ the 
observation in question is likewise confirmed. 

The ascent and descent of the lower border of the liver 
may be observed when the patient is placed with flexed 
knees on a table with the head against a good light. The 
observer stands with his back likewise to the light and fixes 
his vision on the epigastrium. The patient must execute 
forced breathing. The shadow may be traced to both sides 
of the median line of the epigastrium. In women, owing to 
the thoracic type of breathing the shadow, is less evident. 

The shadow may be accentuated, as the author has shown 
in his investigations'"^ of the phrenic shadow, by painting 
the skin (embraced by the shadow) with a saturated alco- 
holic solution of gamboge. 

THE GALL-BLADDER. 

The fundus of the gall-bladder projects beyond the an- 
terior border of the organ. 

A line drawn from the right acromion process to the um- 
bilicus crosses the costal arch approximating the location 
of the gall-bladder. The latter in its long diameter measures 
from 7 to 10 cm., and about 4 cm., in its greatest transverse 
diameter. 

The site of the gall-bladder varies with the position of 
the lower border of the liver and the latter is practically 
always lower than the description in the conventional text- 
book (page 596). 

The reason for the latter error is obvious. The lower 
liver-border is immersed in an atmosphere of tympanitic 
sound and its edge does not exceed one centimeter in thick- 
ness. 

597 



The usual methods of percussion are untrustworthy in 
defining the topography of the organ. 

Two methods are available for mapping out the lower 

liver-border: 




Fig. ijg.— Method of locatmg tlie gall-bladder by the postural method. Tht 
dotted line represents the lower border of the liver obtained by percusuon in the 
usual way. The heavy line represents the lower border obtained by the postural 
method. It is only in this way thai one can account for the different resells ob- 
lained by ciinidana in bailing the lower border of the liver which is really lower 
than is currently supposed. 

I. Postural method. — During percussion, the patient 
inclines the body backward as far as possible, and, to re- 
lieve the tedium of the posture, the body is supported 
means of the hands resting on the hips or by an assistant. 
Percussion must be light (Fig, 139). 

The rationale of this maneuver, I have described els 
598 



Diagnostic Data 

where"^ In the posture suggested, the liver is approximated 
to the abdominal parietes. 

2. Y ago-visceral method. — During light percussion, the 
head is fixed in the position as shown in Fig. 65. 

The rationale of this method involves the principle of 
visceral- tone and is described on page 451. 

Having located the lower liver-border by either of the 
foregoing methods, one seeks t® locate the gall-bladder by 
percussing in the directions shown in Fig. 139. 

The tyftipanitically-dtdl area of the gall-bladder is in 
marked contrast with the dulness of the liver-border. 

In percussing the gall-bladder, the postural or vago- 
visceral method must be maintained. 

Note the following concerning the gall-bladder area of 
tympanitic-dulness : 

1. It descends on inspiration; 

2. It is diminished or disappears after concussion of the 
4th, 5th and 6th dorsal spines; 

3. It enlarges after concussion of the 9th dorsal spine. 

Diagnostic data. — ^The pear-shaped dulness of the gall- 
bladder rising and falling in respiratory rhythm with the 
liver would exclude adhesions. 

Pain due to disease of the gall-bladder may be accurately 
located. 

Riedel^s lobe (a freely movable linguiform body), which 
is common in chronic disease of the gall-bladder, may be de- 
termined by percussion. It may be on either side of, or over 
the gall-bladder. According to the law of Courvoisier, in 
cases of chronic jaundice due to obstruction of the common 
bile-duct, contraction of the gall-bladder signifies that the 
obstruction is due to a stone; dilatation of the gall-bladder 
suggests that the obstruction is due to causes other than a 
stone. 

599 



Spondylotherapy 

This law is based on the fact that in cholelithiasis, the 
gall-bladder is the site of chronic inflammation, and is, in 
consequence, contracted and not capable of dilatation. 
Hence, if percussion shows an enlarged gall-bladder, chole- 
lithiasis may, as a rule, be excluded, and it is evidence in 
favor of a neoplasm. 

Treatment. — In the absence of a stenosis or obstruction 
in the common duct, concussion of the 4th, 5th and 6th dor- 
sal spines eventuates in evacuation of the contents of the 
gall-bladder. 

The latter maneuver is indicated in catarrhal jaundice, 
infectious cholecystitis and in the so-called hepatic inter- 
mittent fever associated with gall-stones. 

Chronic cholecystitis is usually of infectious origin, 
and infection is a frequent exdting cause of gall-stone 
formation. Owing to the anatomic arrangement of the 
c)rstic duct (infolding of the mucosa in the form of 
valves), free drainage of the gall-bladder is difficult and 
the method suggested in treatment may be executed. 

THE PANCREAS. 

The author, as a result of his limited investigations, finds 
that the secretion of the pancreas is probably increased by 
concussion of the 4th, 5th and 6th dorsal spines. 

The investigations were based on the more recent meth- 
ods of determining the function of the pancreas by testing 
for the presence of ferments in the stool. 

Rapid peristalsis is hastened after breakfast of mixed 
food by an enema and calomel (0.2 gm.) and phenolph- 
thalein (0.5). 

Activity of the pancreas is determined by the presence 
in the stool of trypsin and amylopsin. Their absence 
suggests pancreatic insufficiency or obstruction. 

The Wohlgemuth'®^ method for amylopsin is probably 

600 



The P a n c r e a 

the most reliable. One prepares a i per cent, solution of 
Kahlbaum's soluble starch prepared on a water bath for 
about ten minutes with considerable stirring. In the 
absence of a fluid stool, 5 gm. of stool is rubbed up with 
20 C.C. of a physiologic salt solution and after being cen- 
trifuged and filtered varying solutions of this stool-fil- 
trate are added to 5 c.c. of the starch-solution in test- 
tubes. Dilutions of i to 10, i to 100 and i to 1000 suffice. 
To the solution of the starch in the test-tubes, toluol is 
added and the whole digested for 24 hours (38° to 40*^0.). 
At the end of this period, the test-tubes dre almost filled 
with tap-water and one drop of tenth-normal iodin solu- 
tion is added to each tube. If the starch has been com- 
pletely digested no blue color appears in the tube. 

The estimation is made in units; one imit representing 
the ability of i c.c. of stool-filtrate to transform i c.c. of 
starch. If the tube containing the i to 1000 dilution 
transforms 5 c.c. of starch-solution, then i c.c. of undi- 
luted filtrate is capable of digesting 5000 c.c. of starch- 
solution. This represents a normal finding (5,000 imits). 

The minimum number of units is 100, although in the 
tests of Heyn,*<>7 in non-pancreatic cases, they did not 
fall below 250 units. 

In pancreatic disease, the findings may be 50 imits or 
lower. 



601 



Spondyloth e r a p y 



CHAPTER XVI. 
PHYSIO-THERAPY OF PULMONARY TUBERCULOSIS. 

ANEUIC THEORY — CLINICAL EVIDENCE — TRIANGLES OP GROCCO 

METHODS FOR ELICITING LUNG-HVPEREUIA — RESUME TREAT- 
MENT — author's treatment — VISCERAL VASCDLARITY — BI.OOD 
— VOLUME. 

Anemic theory. — According to Rokitansky, one rarely 
encounters pulmonary tuberculosis in association with mitral 
insufficiency for the reason that, in the latter disease, there 
was congestion of the pulmonary vessels. This contention 
despite its assailment still holds. 




Fic. 140. — Semi diagiummatic representation of the pulmonaiy air-vesicles 
(Landois and Stirbng) v, v, blood vessels at the margins of an alveolus; c, c, its 
blood-capilbries E, relation of the squamous epithelium of an alveolus to the 
capillaries in its wall f, aheolar epithelium shown alone; e, e, elastic tissue of the 

lung. 

Orth, obser/ed that, kyphotics despite their limited 
respiratory excursions owed their immunity to tuberculosis 
in consequence of congested lungs. 
602 



Clinical Evidence 

In pulmonary stenosis, tuberculosis is the usual sequela 
owing to pulmonary anemia. 

It was the belief of Bollinger, that tuberculosis showed a 
predilection for the apices for the reason that, they were 
more anemic than other lung-areas owing to gravity. 

The influence of posture on the blood contained in the 
lungs has already been noted on page 290. The vascular 
supply of an alveolus is shown in Fig. 140. 

While the amount of blood in the lungs is influenced by 
gravity, this static factor is not the only one. A very impor- 
tant factor is the activity of the organ {uhi irnlatio^ ibi 
affluxus). 

Pulmonary suction refers to the large quantity of blood 
drawn into the lungs with each inspiration, and this physio- 
logic process has not been inaptly compared to a species of 
dry cupping. Chapman avers, "That if at the termination 
of expiration the quantity of blood in the lungs is from 1-15 
to I- 1 8 of the total quantity of blood in the body, at the ter- 
mination of inspiration, it will be from 1-12 to 1-13." The 
pulmonary vessels expand with each inspiration and con- 
tract during expiration, the result being an increased flow 
of blood from the right heart and lungs; the dilated vessels 
as Campbell puts it, "actually suck the blood out of the 
right heart." 

As is known, lung-anemia aids caseation of tuberculous 
nodules. Tuberculous invasion of the pulmonary apices is 
probably due to impaired circulation ; the posture of the body 
by gravity diminishing the supply of blood to the upper part 
of the lungs. 

Clinical evidence. — One meets with a definite clinical 
picture antedating pulmonary tuberculosis and which, in 
reality, may be the disease itself. The lungs are hyperreso- 
nant and suggest emphysema, there is no postural lung- 

603 



S p n d y I the r a p y 

dullness (page 290), the heart is small and enfeebled, systoUc 
murmurs are heard over the pulmonary artery or aorta or 
both, the triangles of Grocco cannot be elicited, there are 
zones of atelectasis (page 299) and the signs of pulmonary 
anemia (page 301). 

Tissue vulnerability is recognized in certain diseases like 
diabetes and we anticipate cutaneous and other complica- 
tions because sugar is demonstrated in the urine. In pul- 
monary tuberculosis, however, this tissue-susceptibility is 
ignored, although the pretuberculous lung is essentially an 
emphysematous lung, and characterized by hyperresonance, 
extension of the lung-borders, unchanged percussion note 
during both phases of respiration and restricted movements 
of the diaphragm. 

One ascribes the percussion sound over the lungs to vibra- 
tion of the chest-wall and the air within the lung-alveoli, but 
another factor must not be ignored, viz., the quantity of 
blood in the lungs. 

One may reproduce this lung-picture of the pretuber- 
culous lung by concussion of the seventh cervical spine and 
develop an antagonistic picture by concussion of the last four 
dorsal spines. 

In the latter maneuver the maximum effect is seciu^ at 
the tenth dorsal spine. 

In the first maneuver, we have excited the reflex of the 
pulmonary artery (page 526) and diminished the quantity of 
blood in the lungs, whereas in the second maneuver, we have 
dilated the pulmonary vessels (page 607), and increased the 
quantity of blood in the lungs. 

If one carefully auscultates the pulmonary and aortic 
sounds at the end of expiration in pulmonary tuberculosis, 
one will be astounded at the frequency with which murmurs 
of a functional nature are encountered. 

604 



Clinical E v i d e 



nee 



These murmurs are usually systolic pulmonary and aortic 
murmurs, the former being more frequent than the latter. 
No note is taken of subclavian murmurs (page 533), which 
are relatively frequent in phthisis. 

The systolic murmurs, are usually soft and blowing 
sounds, or merely whiffs and they vary in character and ex- 
tent of transmission from time to time. 

The murmurs in question may be due to anatomic lesions 
but in the majority of instances, they are functional and due 
to narrowing of the pulmonary artery and aorta as evidenced 
by the fact that they disappear temporarily after concussion 
of the tenth dorsal spine which dilates both vessels. 

The coarctation of the vessels is in part spasmodic (page 
525), for the reason that the murmurs are heard at one time 
and are absent at another time. 

As a rule, however, the diminished lumina of the vessels 
is a permanent condition. 

Rokitansky noted that too voluminous lungs coupled 
with a small heart characterized the phthisical habitus. This 
observation was relegated to oblivion until revived and vig- 
orously defended by Brehmer. 

The anemia of early phthisis suggests chlorosis and has 
therefore been hyphenated as chloro-anemia. 

In 1872, Virchow, in a monograph, called attention to the 
fact that a diminution of the aortic lumen, attended fre- 
quently by anatomic changes in its walls, was the almost 
invariable result of an autopsy made on a chlorotic individual. 

In some typic instances, the aorta did not exceed a normal 
femoral artery in caliber. In many instances, the pulmonary 
artery was similarly involved, the heart was small and its 
constituent parts proportionately hypoplastic. Another phe- 
nomen was the extreme elasticity of the arterial walls. 

Pulmonary anemia (page 301), is one of the most impor- 

605 



Spondyloth e r a p y 

tant symptoms of early phthisis. The hematologist, however, 
does not concede the existence of anemia in tuberculosis, 
although practically every clinical symptom negatives the 
latter observation. It is quite probable that while the blood 
of the peripheral circulation may show a normal blood count, 
it is not necessarily so with the blood in the rest of the body. 

The investigations of the author show that the quajitity 
of oxygen in the blood in phthisis is diminished (anooce- 
mia) and that the increase of red corpuscles (polycythe- 
mia) is purely compensatory for there is always an 
increase in the number of erythrocytes in the blood when 
the normal process of oxygenation of the body is impaired 
(phthisis, valvular diseases, emphysema, chronic bron- 
chitis, asthma). 

In the phthisical lung, the paravertebral triangles (tri- 
angles of Grocco), are diminished in area or are absent. 
These triangular areas of dullness are found in the norm on 
either side of the spine (Fig. 141); the vertical side of the 
triangle corresponds to the spine, the base to the lower border 
of the lung, while the hypothenuse extends from the apex to 
the outer and lowest point of the base. 

The triangles of Grocco are probably due to passive lung- 
hyperemia as shown by the arrangement of the blood-vessels 
in Fig. 142. The triangles are probably absent in phthisis 
owing to the deficiency of blood in the lungs. 

In the norm, one finds an area of dullness or diminished 
resonance on both sides opposite the 3d, 4th and 5th dorsal 
spines (Fig. 141). I shall designate this area as the vascular 
parallelogram^ because it corresponds to the large pulmonary 
blood-vessels. It disappears, to be replaced by resonance 
when the 7th cervical spine is concussed and is accentuated 
after striking the loth dorsal spine. 

In the norm, one may augment the dull area of the para- 

606 



C I 



n i c a 



I E 



e n c t 



vertebral triangle by concussion of the tenth dorsal spine 
(which increases the quantity of blood in the lung), or dimin- 
ish the area, by concussion of the seventh cervical spine 
(which decreases the blood in the lung). It is also influenced 
by posture (page 290). 



Fig. 141. — Ulustialing the 
rrianglea of Grocco b«low. 




lar paralk-logtam above and iTie 



Taking an average patient, one finds that in the norm, 
if the paravertebral triangle measures 8 cm. at the base, after 
concussion of the tenth dorsal spine, it may be increased to 
15 cm. 

One may also note that the triangles increase in area at 
the end of a forced inspiration (pulmonary suction, page 603) 
and dinainish in area at the end of a forced expiration. An 
hypodermatic injection of adrenalin chlorid (eight minims), 
will maintain an increased area of triangular dullness for 
hours. Thus, before an injection, the base of a triangle 
measured 8.6 cm., whereas after the injection (without 
previous concussion), it measured 14.5 cm. 
607 



S p 



n 



t h 



a p y 



The area of the paravertebral dullness may be selected as 
a guide for the quantity of blood in the lungs, and the author 
in investigating different maneuvers for augmenting lung- 
hyperemia, presents the following table. The duration of 
each maneuver was one minute. 



Method 


Diameter of 
Triangle at Base 


Duration of 
Incr£Askd Paraverte- 
bral DULLNK.S.S 


Concussion at both sides of the 
loth dorsal spine. 


14*9 cm. 


One minute. 


Direct concussion of the loth dor- 
sal spine. 


10.5 cm. 


One-half minute. 


Slow sinusoidal current at both 
sides of loth dorsal spine. 


16 cm. 


Two and one-half minutes. 


Rapid sinusoidal current at both 
sides of loth dorsal spine. 


14 cm. 


One minute. 


High-frequency current at both 
sides of loth dorsal spine. 


1 1.9 cm. 


One minute and forty sec- 
onds. 


Pressure at both sides of loth dor- 
sal spine. 


IS cm. 


Three minutes. 



Compare the foregoing with the table on page 
398. The latter refers to the diffused pulmonary 
dullness the result of an increased quantity of blood 
in the lungs. 

The blood-supply of the lungs is derived from the 
pulmonary and bronchial arteries (nutriment for the 
lung-tissues). Six thousand liters of blood pass through 
the lungs in twenty-four hours. 

Resume. — The author believes that, anemia of the lungs 
is one of the fundamental conditions predisposing to tuber- 
culous infection and that therapeutic maneuvers which pro- 
mote active or passive hyperemia of the lungs are indicated 
in pulmonary tuberculosis. His method of treatment to be 

608 



described presently is marvelously efficient in early cases of 
the disease, but in advanced cases, his results in the main 
were futile. He believes furthermore, that in tuberculosis 
of the joints, the surgeon will yet evolve a method of paralyz- 
ing the vasoconstrictor nerves of a vessel-wall so as to aug- 
ment the supply of blood to the implicated joint. 




Fic. 14a- — Illustrating the arrangcmenl of the pulmonary blood- vi 
(SchultBe-StewaK, atlas of Topographic Anatomy). 



Tkeatment. — Several writers, notably Kuhn and Jacoby, 
have treated phthisis akin to the lines already suggested. 
The former uses a mask of light celluloid with an adjustable 
609 



p 



-y p 



d y I 



t h 



P y 



viilvij which shuts off some o! the air entering through the 
mask, which induces a condition of suction-hj-peremia (Ftg. 
143). The mask is used primarily in the morning and after- 
noon for about fifteen minutes, but later this time is extended 
to an hour or even more. There are many reports concerning 
its great value in phthisis. 




Fig. mj. 



of ihc lungs. 



My investigations show that, the use of the mask elic 
a moderate increase in the area of Grocco's triangle. 

By the method of Jacoby,'°* hyperemia in the lungs i 
induced by lowering the upper part of the trunk by a special 
reclining chair (Fig. 144). 

"■ Autolransjtuion" as he calls his method, Pushes the 
apices and docs away with the conditions favoring the 
tuberculous process. With his chair the entire trunk 
lies horizontally, the head can be slightly raised, while 
the legs lie higher than the shoulders. By this arrange- 
ment, the pelvis is on a line with the chest, not lower than 
!he chest according lo the usual method of reclining. 




I The pelvis can be raised a iittte higher ihan ihe chest hy 

L an interposed cushion which supplements the hyperemia 

K induced by the autotransfusion with compression gf the 

^^^^^ base of the lungs by the pressure of the intestines sliding 

^^^^K down against the diaphragm. The respiration is more 

^^^^B • of the costal type, and the lungs are much better ven- 

^^^^^^ tilated when the trunk Is lying flat than when the patient 



Fic, 144. — Reclinmg chair of Jacaby for auLotransfusioii. 

is half sitting up, possibly with the shoulders stooping 
forward; this actually increases the tendency to anemia 
of the apices. He raises the feet higher by an inch each 
three days, until the feet are 18 inches above the level of 
the head. The patients find that they can breathe more 
deeply and more easily and that expectoration is pro- 
moted. Usually the occasional sharp pains in the chest 
disappeared during this position treatment. The hori- 
zontal attitude is not so agreeable for the patients as 
sitting up but they soon become accustomed to it and 
like it, as they come to appreciate the benefit therefrom. 
The method has been applied in various sanatoria in 
Germany and the general impies^on seems to be 
favorable." 

The investigations of Bier show that hyperemia is na- 
ture's bactericide which is expressed in inflammation (page 



404). 



Spondylotherapy 

The author's treatment. — Every possible, advantage 
is taken of the home-treatment of phthisis by the hygienic or 
open-air method which may be summarized as follows : 

1. Out-door life in a pure air for every variety of case, 
without regard to symptoms, in all weathers and seasons, .for 
whole days, and when possible, all night. 

2. Hyperalimentation by means of nutritious food, prop- 
erly selected and prepared, given at definite and frequent 
intervals. 

3. Moderate exercise stopping short of fatigue and an 
abundance of mental and physical rest. 

4. Judicious medical supervision of every detail of the 
patient's daily life. 

The reclining chair or the bed must be inclined after the 
manner cited on page 292. 

During rest, forced inspirations (which increase the 
volume of blood in the lungs), must alternate several times 
a day with stances of rapid breathing as though an eflfort 
were made to make inspiration and expiration as short as 
possible. The latter exercise is similar in action to the mask 
of Kuhn. 

Daily seances of concussion at the office of the physician 
must be supplemented by paravertebral pressure (page 467) 
at the home of the patient. To protect the skin from the 
effects of pressure, a small piece of adhesive plaster should 
be fixed on either side of the tenth dorsal spine. 

Pressure may be made several times a day but should not 
exceed one minute in duration, otherwise the pulmonary 
artery reflex of dilatation becomes exhausted. The stance 
of concussion for a like reason should not exceed fifteen min- 
utes and must be interrupted. 

If the treatment employed is effective in evoking the 
pulmonary artery reflex of dilatation, the resonance of the 

612 



The A u t h r^ s Treatment 

lung is at once supplanted by dullness on percussion, the 
triangles of Grocco and the vascular parallelogram like- 
wise show accentuated dullness and an augmented area, 
and any systolic murmur over the pulmonic ostium 
disappears. 

m 

It is evident to the reader that, the rapid sinusoidal cur- 
rent may substitute concussion and may in fact, be more 
efficient but as the results attained by the author have been 
mostly effected by concussion, he employs the latter to the 
exclusion of other methods. 

Supplementary treatment. — ^A daily hypodermatic 
injection of adrenalin (page 607) may be employed to aid the 
vascularity of the lung. 

Another efficient aid is daily inunctions of soft green soap 
(sapo viridis), one dram once or tv^ice a day. The acutely 
enlarged glands in scrofula often disappear very rapidly by 
such inunctions. 

The tracheo-bronchial lymph-glands are practically 
always enlarged in phthisis (page 79) and many of the 
S3niiptoms are dependent on such intumescence. 

The almost miraculous results with sapo viridis in 
reducing the enlarged glands in scrofula have suggested 
to the author its employment in phthisis. 

It is difficult to define the rationale of such inunctions. 
Sapo viridis consists principally of potassium oleate. 

It is known that consumption is notably absent 
amongst laborers in lime kilns and those who drink 
hard water. 

The phenomena of life, according to Loeb, depend 
upon the presence in the tissues of a number of the 
various metal proteids, or soaps (Na, Ca, K, and Mg) 
in definite proportions. 

By aid of the calcimeteTy it has been demonstrated that 
there are a number of diseases dependent on an excess 
or diminution of lime salts in the blood. When the 

613 



Spondyloth e r a p y 



■■ 



estimation shows an excess of lime, dtric add is em- 
ployed, and caldum chlorid when the lime is defident. 
The parathyroids probably control caldum metabolism. 
Symptoms (muscular twitching, tachypnea, etc.), fol- 
lowing parathyroidectomy, may be cured by intravenous 
injections of a 5% solution of caldum lactate. 

Visceral vascularity. — ^That one may influence the 
vascularity of tissues by stimulation of the seventh cervical 
spine or the tenth dorsal spine can be easily demonstrated. 

During the time that a rapid sinusoidal current was ap- 
plied I have had several competent oculists, notably, Dr. 
Wm. Hopkins and Dr. Morton Hart, examine the eyes 
ophthalmoscopically. All noted the immediate anemia of 
the fundus when the current was applied to both sides of the 
seventh cervical spine and hyperemia of the fundus, when 
application was made at the tenth dorsal spine. In this way, 
one could at will induce hyperemia or anemia. Expectant 
attention on the part of the observers was excluded by not 
apprising them of the object of my investigations. 

The same precautions were taken in a bronchoscopic 
examination made for me by Dr. Henry Horn, one of the 
most competent bronchoscopists in the world. His report 
is as follows : 

"The following is a report on the Bronchoscopic find- 
ings in the case of Mr. X., made this morning: 

The examination was made in the following way: A 
few drops of a 3% cocain solution was sprayed on the 
posterior pharyngeal- wall. An applicator, dipped twice 
in a 20% sol. of cocain was applied to the interior of the 
larynx but did not extend below the cords. 

Examination i. 

The region just above the bifurcation was very care- 
fully examined with the 7.5 B running's tube. The 
mucous membrane was very pale and pasty looking. 

614 



Visceral Vascularity 

The small folds between the rings were not injected. 
Gradually, occupying a time-period roughly estimated 
at from 3-5 seconds, the folds between the rings gradu- 
ally became very distinctly injected and one could see a 
faint rosy blush spreading over the other portions of the 
mucous membrane. After an interval of a minute the 
mucous membrane became pale again, the blush dis- 
tinctly faded and the injection in the small depth between 
the rings became paler but the injection did not entirely 
disappear. This phenomenon was repeated, apparently 
at the will of the operator who carried out some electrical 
manipulation which I could not follow, several times. 
One could distinctly tell when the pallor commenced 
and when the mucous membrane commenced to become 
more congested. 

The same experiment was carried out in the larjmx 
itself. The posterior interarytenoid space was selected 
because there was a very tiny plexus of veins visible. 

Here at a given time the small plexus became dis- 
tinctly paler, and after a few seconds interval the veins 
began to fill and the blush extended distinctly downward 
over the posterior fold. 

A patient present at the time who had no idea of the 
object of the experiment, was told to look down the tube 
and tell what she saw. She also distinctly saw the plexus 
grow distinct'/ pale, or injected at the will of the opera- 
tor." 

Comment by the Author, — Pallor was produced with 
the slow sinusoidal current at the 7th cervical spine and 
congestion, when the electrodes were applied at the loth 
dorsal spine. The laryngeal changes were deserving of 
special consideration insomuch as the mucosa was al- 
ready blanched by the cocain. 

If one inspects the nasal mucosa, one may observe 
anemic or hyperemic effects according to the site of the 
application of the current. Like vascular phenomena 
are demonstratable in the ear-drum. 

Despite the contention of the physiologist that the 

615 



S p n d y I t h e r a p y 

pulmonary vessels are iinprovided with vasomotor 
nerves, the clinical investigations of the author suggest 
the probable incorrectness of the dictum in question. 

The fact that anemia or h3rperemia may be induced at 
will by the clinician, suggests many possibilities in the 
treatment of disease. Thus insomnia may be influenced, 
the oculist may render the eye anemic in ocular inflam- 
mations, or he may augment the supply of blood in con- 
ditions demanding it. However, the author is not in a 
position to speak authoritatively on the subject. He 
merely suggests this therapeutic resource in the treat- 
ment of a multitude of conditions and hopes that time 
and the experience of others may establish its value. 

He believes that hemoptysis may be controlled by 
application of the sinusoidal current (the rapid, pre- 
ferably) to either side of the seventh cervical spine and, 
in the absence of the current, pressure may be used. 

The author may be permitted to observe parentheti- 
cally, that amyl nitrite is the most efficient and expedi- 
tious expedient we possess in hemoptysis. ^^^ Unless it is 
efficient after the first administration, subsequent in- 
halations do no good. The value of the drug for this pur- 
pose has been extensively confirmed and Hare, who 
signalizes this drug as a specific in uterine hemorrhages, 
claims that it may even arrest menstruation. Atten- 
tion must likewise be directed to the author's treatment 
of LOCOMOTOR ATAXIA. He started from the 
conviction that, the lesions peculiar to this disease are 
primarily resident in the spinal vessels. Thus, the 
spinal sclerosis in ergotism resembles in distribution the 
degeneration peculiar to tabes. One also finds sclerosis 
of the dorsal and lateral columns associated with pro- 
found anemia. 

Now, arteriosclerotic vessels are not rigid tubes but 
respond to reflex influences by spasmodic contraction. 
In tabes, the paroxysmal pains and crises are probably 
caused by a transient angiospasm (paroxysmal claudica- 
tion of spinal cord), and the author has frequently re- 

616 



Comment by the Author 

lieved these symptoms by inhalations of amyl nitrite. In 
early tabes, by inhalation of the latter, he has tempo- 
rarily restored the lost knee-jerk. In tabes, concussion of 
the loth dorsal spine, which augments the vascularity of 
^.he spinal cord, has given me most encouraging results, 
coupled with concussion of the lumbar spines. 

The eminent clinician. Dr. H. Jaworski, of Paris, 
France, author of a work on "locomotor ataxia," reports 
several remarkable results obtained by this method. In 
reporting one case, he comments as follows: "Called 
into consultation by a confrere, I saw the hopeless case 
of a woman, who was unable to stand for five years. 
After a stance of ten minutes, she could walk without a 
cane and now comes daily to my office for further treat- 
ment. Other symptoms have improved. This case is a 
real miracle." 

Another curious fact, in connection with the author's 
treatment of phthisis by concussioft of the loth dorsal spine, 
is the enormous increa.se in the number of red corpuscles 
following the maneuver. This increase varies from icxd,ooo 
to 600,000 corpuscles per cubic millimeter. At first it was 
supposed that this artificial polycythemia was due to some 
effect on the bone-marrow but other investigations demon- 
strated that pressure, sinusoidal and high-frequency cur- 
rents to the same region eventuated in like results. 

Concussion of the 7th cervical spine, on the contrary, 
caused an average reduction of 500,000 red corpuscles. 
Estimations were made immediately after concussion. 
Whereas concussion of this spine causes an increase in the 
specific gravity of the blood, concussion o^ the loth dorsal 
spine diminishes the specific gravity. 

Blood- Volume. — The foregoing facts suggest many 
things in clinical pathology, notably, the causation of 
edema in nephritis (page 632). Concussion of the spines 
in question does not cause any appreciable change in the 

617 



Spondyloth e r a p y 

blood-pressure which is in accord with the physiologic 
axiom that, when the vessels are overfilled or contain 
less than the normal quantity, mechanisms are present 
for maintaining the blood-pressure at its normal height. 
My investigations suggest that the caliber of the blood- 
vessels is not constant and that the change in limien is 
practically a compensatory angiospasm or angiectasis to 
accommodate respectively a decreased or increased 
volume of blood. One may easily demonstrate in- 
creased volume of the organs after conciission of the loth 
dorsal spine, or diminished volume by concussion of the 
7th cervical spine. 

The observation of the older writers of the "full- 
blooded" (plethora) condition of the patient, played an 
important part in hematology, but the observation suc- 
cimibed to the rigid analysis of modem methods despite 
the fact that, its confirmation was empirically demon- 
strated by the relief afforded by blood-letting. Bleeding 
was so inconsistently practiced by the past generations 
of physicians that it merited the rebuke of Van Helmont, 
that "a bloody Moloch presides in the chairs of medi- 
cine." Blood-letting is one of the lost therapeutic arts. 
Formerly we bled too much, but now we do not bleed 
enough. 



bl8 



Treatment of Whooping Cough 



CHAPTER XVII. 

TREATMENT OF WHOOPING COUGH. 

PERTUSSIS — author's CONCEPTION OF PERTUSSIS — AUTHOR'S TREAT- 
MENT — RESULTS OF TREATMENT — ANALYSIS OF TREATMENT. 

Although it is conceded that pertussis is an infectious and 
contagious disease, the nature of the infection has not been 
definitely demonstrated. A bacillus, resembling the bacillus 
of influenza, has been found, which many believe is the 
pathogenic organism of pertussis. 

The disease, after a period of incubation lasting from 
seven to ten days, is characterized by a catarrhal and par- 
oxysmal stage. The former stage, after a duration of from 
seven to ten days, is succeeded by the latter stage, in which 
the cough becomes more convulsive and is characterized by 
the distinctive and diagnostic ^^ whoop. ^'^ 

Including its complications, pertussis is the most fatal 
infectious disease in children under the age of five years. 

Respecting the conventional treatment of the disease, 
the therapeutic pessimism of Osier is sententiously expressed 
as follows: "Six weeks and a good big bottle of paregoric." 

The entire duration of an average case of pertussis is 
from ten to twelve weeks or even longer. 

Voelcker,"® in his contribution embracing a careful study 
of over 550 cases of pertussis, concludes that, "the treatment 
of whooping-cough constitutes one of the reproaches to the 
art of medicine. We have no method by which we can 
shorten the disease, nor can we do more than pilot the case 
to recovery, modifying, symptoms, guarding against com- 

619 



Spondyloth e r a p y 

plications, and making our patients as comfortable as we 
can during an illness which has no rival in its discomforts. 
A specific for whooping-cough has yet to be found. To all 
those I have tried (and they are over thirty in number), the 
handwriting on the wall is literally applicable; "Tekel" 
("Thou art weighed in the balances, and art found want- 
ing/') 

The author's conception of pertussis. — It is an in- 
fectious disease in which the infection diminishes vagus-tone 
(chapter XIII). This reduction in tone specially imph- 
cates the vagus-fibers innervating the aorta. The latter ves- 
sel even in health does not show a constant lumen, in fact, 
its caliber is modified by physiologic conditions and periph- 
eral irritants may cause it to dilate. When paroxysms of 
pertussis are precipitated by emotions, sneezing, irritation 
of the throat, etc., there is a temporary aortectasis. Aortic 
dilatation follows emotional disturbances owing to an in- 
crease of adrenalin secretion (page 466.) 

I have made careful examinations of the aortic area be- 
fore and after irritation of the nose, throat and other regions 
and noted as a result of such irritation, an invariable increase 
in the caliber of the aorta. 

In an infant of eight months, the distance between the 
manubrium stemi and the vertebral column is only 2.2 cm., 
and it is quite evident that the slightest increase in the caliber 
of the aorta will produce pressure-symptoms on important 
structures. 

Reference to Fig. 122, will show the important structures 
contiguous to the aorta which are irritated by dilatation of 
the latter and symptoms develop somewhat analogous to 
aneurysm. In fact, the cough of the latter is not unlike that 
observed in some cases of pertussis. 

In children as well as in adults, one encounters in per- 

620 



Treatment of Whooping Cough 

tussis, aphonia and dysphonia which we are inclined to 
attribute to excessive coughing, whereas in reality, they are 
probably pressure-symptoms. I have noted dysphagia in 
two adults with pertussis and one knows that the mere act 
of swallowing may precipitate a paroxysm in children. We 
have commented on the limited sagittal diameter of the chest 
in children. The lumen of the trachea is maintained by 
vagus-tone and we know that, when the latter is diminished, 
the trachea dilates and still further encroaches on the limited 
intra-thoracic area. Changes in the lumen of the trachea 
are more frequent in children than in adults owing to the 
undeveloped condition of the bronchial tree.* Bronchoscopy 
shows that, even in the norm, the systolic projection of the 
left tracheal wall by the adjacent aorta is considerable. 

Aside from the characteristic "whoop," or a series of ex- 
piratory coughs in the absence of the latter, and a marked 
leucocytosis (chiefly of the lymphocytes), there are no path- 
ognomonic symptoms of pertussis. 

A symptom which I have found to be almost invariably 
present is either an increase in the area of aortic dullness on 
percussion or the dullness in question is accentuated. This 
may be found in adults as well as in children. The area of 
dullness in children is about the size of a dollar and is located 
over the arch of the aorta at, or on either side of the manub- 
rium stemi. The area of dullness is increased by pressure 
between the third and fourth dorsal spines (page 472), which 
reduces vagus-tone and dilates the aorta or, by concussion 
of the four last dorsal spines or the loth dorsal spine, which 
provokes the aortic reflex of dilatation (page 255). The area 
of dullness is diminished or disappears by increasing vagus- 
tone (pressure at the seventh cervical spine or concussion of 
the latter). 

♦According to Przewoski, tracheal dilatation is the rule in chronic coughs. 

621 



Spondylotherapy 

ment of the gland is movable : The lower border of thymus 
dullness being defined (the pleximeter-finger still in place), 
retract the head to its fullest extent. Thymus-dullness rises 
upward toward neck, leaving a clear resonance on percussion. 
Mediastinal glands and other enlarged structures do not 
show this shifting dullness. Aberrant and accessory thyroids 
must also be taken into account in the differentiation of 
retrosternal dullness. 

The author's treatment of pertussis. — ^This, as al- 
ready suggested, is based on the hypothesis that there is a 
local vagus-hypotonia involving the fibers innervating the 
aorta and that, while the disease is not necessarily curtailed, 
its violence is minimized by subduing the factor {aoriecUisis) 
to which may be attributed many of the symptoms. 

There is little doubt in the nund of the writer that some 
infections are responsible for a like condition. Thus diph- 
theria is said to be complicated with pertussis (perhaps a 
pseudo-pertussis). Here, the vagus-hypotonia may not only 
be responsible for the characteristic cough but also for the 
heart-symptoms and paralyses peculiar to diphtheria. The 
suggestion having been made, the author awaits the con- 
firmation of his theory. 

The following letter was addressed to a few colleagues : — 

"The following simple method has arrested the 
paroxysms of whooping-cough in a number of patients in 
from 3 to 7 days: 

"Place a pleximeter upon the spinous process of the 7th 
cervical vertebra and strike the pleximeter a series of 
moderate blows with a percussion-hammer. The num- 
ber of blows is of little moment but the blows must be as 
strong as the child can tolerate without flinching. Some 
of the mothers accompany the blows with a nursery 
rhyme or song to interest the child. In the absence of a 
pleximeter and percussion-hammer, a strip of linoleum 

624 



Author^s Treatment of Pertussis 

and a tack-hammer will suffice. To avoid cutaneous 
irritation, cotton may be interposed between the strip 
of linoleum and the spine. Each stance during 
the interparoxysmal period should last 5 minutes thrice 
daily and the harmless method may be executed by the 
mother or nurse. The undersigned is desirous of col- 
lecting reports on this method of treatment from his 
colleagues and to test the efficiency of the treatment, it 
would be well to note the number and severity of the 
paroxysms before and after treatment in each patient. 

'^The undersigned will explain the rationale of the 
method in a contemplated contribution and will ap- 
preciate the reports sent to him by his confreres. 

''This method has also succeeded in some cases of 
laryngismus stridulus, ^^ 

Pressure (page 467), or the sinusoidal current to the 
seventh cervical spine, would prove equally effective but the 
results noted refer to the use of concussion only. 

A number of replies were received from physicians 
throughout the United States v^ho came to San Francisco to 
study the methods of spondylotherapy and from others. A 
few replies will be cited. 

Dr. Geo. H. Baert, Grand RAPros, Mich.: 

''I have cured by your concussion-method, more than 
twenty cases of pertussis within two weeks. Last week, 
a patient, Mrs. S., age 30, consulted me for whooping- 
cough. She received only four treatments and her 
paroxysms ceased after the second treatment." 

Dr. a. L. Gates, Los Angeles, Cal.: 

''Mrs. X. had approximately 24 paroxysms in twenty- 
four hours. After three days, paroxysms were reduced 
to six a day. The disease was not curtailed in duration, 
perhaps owing to the fact that the rapid improvement 
noted by the patient caused her to neglect coming to my 
office." 

625 



Spondylotherapy 

Dr. E. Gallimore, San Jose, Cal.: 

"Patient, age 71 years. Whooping-cough for 8 dajrs 
with 10 to 12 paroxysms in the twenty-four hours. After 
three days, paroxysms reduced to three in twenty-four 
hours, of a very mild character and patient declares 
herself as well." 

"Patient, age 3 years. Seven to eight paroxjrsms in 
twenty-four hours, and very severe at night. After 
treatment for seven days her aunt informs me that the 
paroxysms are so mild and infrequent that they are not 
noticed." 

"Patient, age 4 years. Five to six paroxysms in twenty- 
four hours reduced to three attacks in the same time 
after one week." 

"Patient, age 6 years. Before treatment, eleven to 
fourteen paroxysms in twenty-four hours. Reduced in 
one week to five mild attacks." 

"Age 18 months. Six to eight severe paroxysms in 
twenty-four hours. After one week, reduced to three 
milder attacks." 

"Age 2 years. Fifteen paroxysms before treatment. 
After four days, reported to have had only one attack 
during night." 

"Age 3 years. When treatment was commenced, was 
having six to nine attacks in twenty-four hours. After 
six days, is practically cured." 

Ten other cases are reported by Dr. Gallimore, and 
the results correspond with those cited. 

Dr. L. Lore Riggin, Oakland, Cal.: 

"If a drug could be found to produce such a marked 
change, we would herald it as "The find of the day." 
Treatment of itself is of great value but I find need at 
times to give a placebo to satisfy parental minds. The 
great trouble is to get the parents to persist in the treat- 
ment and to make the percussion sufficiently hard. The 
results are in direct proportion to the care and attention 
of executing the treatment. It is very gratifying to 
know that the disease need not "run its course." In no 

626 



Analysis of Treatment in Pertussis 

case has there been a single complication and no patient 
has lost flesh. One very interesting case came under 
my care after suffering intensely for six weeks; the 
mother was very much discouraged and willing to do 
anything. Patient was nine years old, had lost flesh and 
had a bad bronchitis. This patient returned to school, 
with weight restored, in less than three weeks." 
Some random reports are as follows: 

"Attacks every hour during the night. Treatment 
commenced in third week of disease. After the fourth 
day no attacks at night." 

"Noiseless concussion-hammer (electric) used on a 
child, age 6 years. Treatment lasted ten minutes. No 
attacks after the first treatment. Sister of this patient 
had a continuance of attacks of less severity, even after 
eight treatments." 

"Infant. Attacks partially controlled in two, and 
completely after five days. In a boy in the same family, 
no apparent results." 

"The results of your treatment are in proportion to 
the efficiency of its execution. All my cases (14), have 
progressed splendidly, excepting two, in the family of a 
physician." 

"A child had lost very much in weight in consequence 
of vomiting following severe attacks. Vomiting no 
longer occurred when treatment was given just before 
meals, and the patient rapidly regained weight." 

Analysis of treatment in pertussis. — ^An analysis of 
the medicinal and non-medicinal therapy of this disease 
demonstrates two things : An inhibition or an augmentation 
of vagus-tone. Reference on page 453 has already been made 
to the influence of drugs on the tone of the vagus. 

Belladonna shows its best action when pushed to its full 
physiologic eflfects. Here, the results are attained by dimin- 
ishing vagus-tone (page 472). 

Antipyrin, one of the most eflficient drugs in subduing the 

627 



Spondylotherapy 

paroxysms, likewise achieves its action by reducing, but not 
like the former drug, by annihilating vagus-tone. 

Many years ago, sulphate of quininy .was regarded as a 
specific in whooping-cough, used in solution as a spray to the 
mouth and throat. This method was abandoned. As a 
matter of fact, the author finds that quinin given to secure 
and maintain its physiologic action is one of the very best 
drugs for increasing vagus-tone (page 505). 

By the use of Kilmer^s belt, it is claimed that the vomiting 
spells in pertussis are reduced from 85 to 95 per cent. A 
band of linen is used, 4 to 5 inches wide and 3 inches less in 
length than the circumference of the abdomen of the child 
at the navel, with two strips of elastic webbing, each two 
inches wide let in at each side, the whole belt lacing at the 
back. The belt must be tight and worn night and day. 

The results with the belt are no doubt effected by reflex 
stimulation of the vagus (page 208). We know that pressure 
upon the abdomen will stimulate the vagus even to inhibition 
of the heart. Thus, when H6nck,'" recommends abdominal 
massage in the treatment of pertussis, claiming cures in less 
than three weeks, the results are probably attained by reflex 
stimulation of the vagus. 

In conclusion, attendants should learn the following 
simple method of inhibiting paroxysms of pertussis; press 
the lower jaw of the patient downward and forward as is 
often done during the administration of an anesthetic to 
bring the tongue forward. 



628 



Miscellaneous Data 



CHAPTER XVIII. 

MISCELLANEOUS DATA. 

FURTHER ADVANCES IN THE UTILIZATION OF THE KIDNEY REFLEXES 
— ^PROSTATIC HYPERTROPHY — REFLEXOTHERAP Y — SPOND YLO- 
THERAPY IN THE ETIOLOGY OF DISEASE — SYNOPTIC TABLES 
OF SPOND YLODIAGNOSIS, SPONDYLOTHERAPY AND PHARMA- 
COLOGY OF THE REFLEXES — SPOND YLO-THERAPEUTIC ARMA- 
MENTARIUM. 

FURTHER ADVANCES IN THE UTILIZATION OF THE KIDNEY 

REFLEXES. 

On page 359, reference has been made to the kidney 
reflexes and it was noted that the kidney reflex of dilatation 
was elicited by concussion of the 6th to the 8th dorsal spines 
and the counter reflex of contraction, by concussion of the 
12th dorsal spine. Since then, howeyer, the author has 
found that a more decided contraction of the kidney can be 
evoked by concussion of the ^th cervical spine, and a more 
decided dilatation, by concussion of the loth dorsal spine. 

Without^ entering into the details of the investigations, it 
suffices to say tha